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NERVOUS  AND  MENTAL 
DISEASES 


ARCHIBALD  CHURCH,  M.D. 

Professor  of   Nervous  and    Mental   Diseases  and   Medical   Jurisprudence  in  the   Northwestern  University 

Medical  School  (the  Chicago  Medical  College),  Chicago;   Late  Professor  of  Neurology 

in  the  Chicago  Policlinic ;   Neurologist  to  St.  Luke's,  Wesley,  Mercy, 

and  Chicago  Hospitals;  Consulting  Neurologist  to  the  Home 

for  Destitute  Crippled  Children,  Chicago,  etc. 


FREDERICK  PETERSON,  M.D. 

President  of  the  State  Commission  in  Lunacy,  New  York ;    Chief  of  C'inic,  Department  for  Nervous  and 

Mental  Diseases,  Columbia  University;    Instructor  in  Mental  Diseases,  Columbia 

University;    Ex-Presidcnt  of  the  New  York  Neurological  Society 

General  Consultant  to  the  Craig  Colony 

for  Epileptics. 


WITH  338  ILLUSTRATIONS 


FOURTH  EDITION,   THOROUGHLY  REVISED 


PHILADELPHIA,   NEW   YORK,   LONDON 

W.  B.  SAUNDERS  &  COMPANY 
J903 


SET    UP,    ELECTROTYPED.    PRINTED,    AND    COPYRIGHTED    MARCH,    l8 

REPRINTED    OCTOBER.    1899        REVISED,  REPRINTED,    AND 

RECOPYRIGHTED    JULY,    I9OI         REPRINTED 

APRIL,  ig02.      REVISED.  REPRINTED, 

AND   RECOPYRIGHTED 

AUGUST,    3903. 


Copyright,  1903,  hy  W.   15.   Saunders  &  Company 


Registered  at  Stationers'   Hall,  London,  England 


PRESS    OF 

W.   B.  SAUNDERS   &   COMPANY 

PHILADELPHIA 


PREFACE  TO  THE  FOURTH  EDITION. 


Opportunity  for  a  fourth  edition  enables  the  interpolation  of 
new  matter  of  considerable  importance.  The  question  of  the  healing 
of  nerves  has  had  new  light  thrown  upon  it  by  recent  investigations, 
and  these  views  are  embraced  in  the  present  edition.  The  subject  of 
Intermittent  Limping  has  also  received  a  section.  Herpes  zoster,  which 
is  now  definitely  known  to  depend  upon  a  lesion  of  the  posterior  root 
ganglia,  may  be  considered  as  essentially  a  nervous  disorder,  and  is 
given  a  section  in  its  proper  place.  That  ibrm  of  epilepsy  n^arked 
by  myoclonus,  furnishing  the  so-called  Combination  Disease,  is  de- 
scribed. More  space  has  been  given  to  syptomatology  and  sympto- 
matic disorders.  The  value  of  astereagnosis  and  of  Kernig's  sign  in 
their  diagnostic  relations  has  been  elaborated.  Quite  a  number  of  new 
cuts  have  been  added  and  the  text  has  been  carefully  revised  throughout. 

In  the  portion  of  the  book  devoted  to  Insanity  the  chief  addition 
consists  of  a  new  section  prepared  for  the  work  by  Dr.  Adolpli  Meyer, 
Director  of  the  Pathological  Institute  of  the  New  York  State  Hospitals, 
under  the  jurisdiction  of  Dr.  Pete;rson.  This  new  section  consists  of  a 
critical  review  of  the  German  schools  which  have  recently  made  such 
important  changes  in  our  point  of  view  in  psychiatry. 

The  continued  favor  with  which  the  book  is  received  is  a  great 
gratification  to  its  authors. 

Septeinbcr,  1903. 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/nervousmentaldis1903chur 


PREFACE. 


This  book  has  been  written  for  medical  students  and  general  prac- 
titioners. It  makes  no  claim  to  be  other  than  a  carefully  prepared 
text-book.  The  literature  of  neurology  and  psychiatry  has  been  sifted 
by  the  authors,  and  such  digest  revised  in  the  light  of  their  own 
experience  in  practice  and  in  teaching.  They  have  attempted  to 
present  their  facts  clearly,  directly,  and  with  brevity,  despite  the  diffi- 
culty of  condensing  two  great  subjects  within  the  limits  of  a  single 
volume. 

This  is  not  the  joint  work  of  two  writers,  but  each  author — Dr. 
Church  in  Neurology,  and  Dr.  Peterson  in  Psychiatry — has  con- 
tributed to  the  making  of  a  single  volume  what  might  have  made 
a  separate  monograph  ;  each  is,  therefore,  solely  responsible  for  the  work 
in  his  own  department.  In  placing  the  correlated  sciences  neurology 
and  psychiatry  under  the  same  cover,  the  reader's  convenience  was 
considered. 

An  unusual  number  of  illustrations  for  each  department  (from  the 
authors'  own  material,  except  when  otherwise  indicated)  has  been 
allowed  by  a  generous  publisher. 


CONTENTS. 


NERVOUS  DISEASES. 

PART  I. 

PAGE 

Examination  of  Patients 17 

Chapter        I.  The  Anamnesis 17 

Chapter       II.  The  General  Physical  Examination 23 

Chapter     III.  The  Muscular  System 27 

Errors  of  Motility 27 

The  Reflexes 31 

Chapter      IV.  Trophic  Conditions 37 

Chapter        V.  Electrical  Conditions 39 

Chapter      VI.  Sensory  Conditions 49 

The  Tactile  Sense •  50 

The  Pain  Sense 51 

The  Pressure  Sense 51 

The  Thermic  Sense 51 

The  Muscular  Sense 51 

Pain 56 

Chapter    VII.  The  Special  Senses      Gl 

Sight Gl 

Hearing 64 

Smell 65 

Taste 65 

Chapter  VIII.  Speech 66 

PART  II. 

Diseases  of  the  Cerebral  Meninges  and  Cranial  Nerves 71 

Chapter         I.  Cerebral  Meninges 71 

Pachymeningitis 73 

Pial  Hemorrhage 75 

Chapter       II.  Inflammation  of  the  Pia  Mater 77 

Acute  Leptomeningitis 77 

Chronic  Leptomeningitis 78 

Chapter     III.  Tubercular  Meningitis 79 

Chapter      IV.  Diseases  of  the  First  and  Second  Cranial  Nerves 95 

Chapter        V.  Diseases  of  the  Ocular  Nerves 103 

Chapter      VI.   Diseases  of  the  Trifacial  Nerve 113 

Chapter    VII.   Diseases  of  the  Facial  Nerve 117 

Chapter  VIII.  Diseases  of  the  Eighth  Cranial  Nerve 126 

Chapter     IX.   Diseases  of  the  Glossopharyngeal,  Vagus,  and  Accessory  Nerves     .  132 

Chapter       X.  Diseases  of  the  Spinal  Portion  of  the  Accessory  Nerve 143 

Chapter     XL   Disease  of  the  Hypoglossal  Nerve 146 

Chapter    XII.  Multiple  Paralyses  of  Cranial  Nerves 149 

11 


Chapter 

I. 

Chapter 

II. 

Chapter 

III. 

Chapter 

IV. 

Chapter 

V. 

Chapter 

VI. 

Chapter 

VII. 

Chapter 

VIII. 

Chapter 

IX. 

Chapter 

X. 

Chapter 

XL 

12  CONTENTS. 

PART  m. 

^  PAGE 

Diseases  of  the  Brain  Peopek 159 

The  Cerebral  Cortex — Localization 159 

Speech  and  the  Cortex — Aphasia 168 

III.  The  Cerebral  White  Matter,  Basal  Ganglia,  and  Cerebellum   .    .    .  179 

Further  Localizing  Considerations 186 

Arterial  Brain  Diseases 191 

Cerebral  Anemia  and  Hyperemia 193 

Cerebral  Arteritis 196 

Cerebral  Hemorrhage  and  the  Hemiplegic  State 201 

Cerebral  Softening             .    .        216 

Diseases  of  the  Cerebral  Veins  and  Sinuses 225 

Cerebritis,  Encephalitis,  and  Abscess  of  the  Brain 232 

The  Cerebral  Palsies  of  Children     . 240 

Tumors  of  the  Brain 250 

Chapter   XII.   Hydrocephalus 263 


PART  IV. 

Diseases  of  the  Spinal  Meninges  and  Spinal  Nerves 268 

Chapter         I.  Spinal  Meningitis  and  Spinal  Meningeal  Hemorrhage 268 

Chapter       II.  Injuries  and  Diseases  of  Spinal  Nerves 276 

Chapter     III.  Lesions  of  Special  Spinal  Nerves 286 

The  Cervical  and  Brachial  Plexuses 286 

Combined  Palsies  of  the  Nerves  of  the  Arm 293 

Nerves  of  the  Trunk  .  296 

Nerves  of  the  Lower  Extremity 296 

Chapter      IV.  Multiple  Neuritis , 304 

Chapter       V.  Herpes  Zoster 324 

PART  V. 

Diseases  of  the  Coed  Proper 327 

Chapter        I.  Localization 327 

Chapter      II.  Indiscriminate  Cord  Lesions 348 

Traumatic  Lesions  of  the  Cord  Substance 348 

Hemorrhage  into  the  Cord 348 

Thrombotic  Softening  of  the  Cord      351 

Myelitis 351 

The  Paraplegic  State 359 

Landry's  Paralysis 362 

Caisson  Disease,  or  Divers'  Palsy 366 

Tumors  of  the  Spinal  Cord  and  Its  Envelopes 368 

Spina  Bifida 372 

Chapter     III.  Lesions  and  Diseases  of  the  Spinal  Gray  Matter 374 

Acute  Anterior  Poliomyelitis 374 

Syringomyelia <^82 

Progressive  Muscular  Atrophies  Shovping  Lesions  of  the  Spinal 

Gray      .  388 

Progressive  Muscular  Atrophies  vpithout  Striking  Cord-lesions  .  396 

Arthritic  Muscular  Atrophy 407 


CONTENTS.  13 

PAGE 

Chapter      IV.  Lesions  Affecting  the  White  Matter  of  the  Cord 410 

Tabes  Dorsalis 410 

Combined  Scleroses  of  the  Spinal  Cord      444 

Combined  Cord-lesions  in  Anemias  and  Cachexias 448 

Family  Ataxia -'oO 

Hereditary  Spastic  Paraplegia 45G 

Sclerosis  of  the  Cord  Due  to  Vegetable  Intoxicants 457 

PART  VI. 

Diseases  of  the  General  Neevous  System  with  known  Anatomical 

Basis 459 

Chapter        I.  Multiple  Cerebrospinal  Sclerosis 459 

Chapter       II.  Syphilis  of  the  Nervous  System 467 

Cerebral  Syphilis 469 

Spinal  Syphilis 475 

The  Parasyphilitic  Diseases 479 

PART  vn. 

Diseases  of  the  Nervous  System,  without  Known  Anatomical  Basis    .    .  481 

Chapter        I.  Trophoneuroses 482 

Acromegalia 482 

Hypertrophic  Ost«o-arthropathy 488 

Hj'perostosis  cranii 489 

Myxedema 490 

Exophthalmic  Goiter 497 

Scleroderma 507 

Eaynaud's  Disease =  509 

Acroparesthesia       511 

Intermittent  Limping   ....        512 

Angioneurotic  Edema 513 

Localized  Hj'i^ertrophies 515 

Chronic  Hereditary  Tropho-edema =  519 

Chapter       II.  Infection  Neuroses 521 

Tetanus .  521 

Hydrophobia 523 

Tetany 526 

Chorea 530 

Chapter     III.  Motor  Neuroses 542 

Huntingdon's  Disease 542 

Myoclonia 543 

Dubini's  Disease 545 

Parkinson's  Disease,  Paralysis  Agitans .    .  546 

Thomsen's  Disease  (Myotonia') 552 

Family  Periodic  Paralysis 554 

Family  Tremor 556 

Chapter      IV.  Fatigue  Neuroses 556 

Writers'  Cramp      557 

Other  Occupation  Neuroses 562 

Chapter       V.  Neurasthenia 563 

Chapter      VI.  Hysteria 574 

Stigmata  of  Hysteria 576 

Accidents  of  Hysteria 584 


14  CONTENTS. 


PAGE 


Chapter    VII.  Epilepsy 602 

Chapter  VIII.  Migraine , 615 

Chapter     IX.  Neuroses  following  Traumatism ,  619 

Chapter       X.  Tics 621 

PART  vm. 

Symptomatic  Disoedees 625 

Chapter        I.  Neuralgia 625 

Chapter       II.   Disorders  of  Sleep 630 

Wakeful  Disorders  of  Sleep 632 

Somnolent  Disorders  of  Sleep 636 

Sleep  Palsies 637 

Hypnotism 638 


MENTAL  DISEASES. 

Chapter         I.  Definition  and  Classification  of  Insanity 643 

A  Review  of  Eecent  Problems  of  Psychiatry 650 

Chapter       II.  General  Etiology  of  Insanity 688 

Sex 688 

Age 688 

Heredity      689 

Strain 712 

Chapter     III.  General  Symptomatology  of  Insanity 726 

Disorders  of  Sensation 727 

Disorders  of  Ideas 733 

Affective  Disorders 735 

Disorders  of  the  Idea-associations 738 

Disorders  of  Actions 747 

Accompanying  Physical  Disorders 749 

Chapter      IV.  Examination  of  the  Patient  ;  Diagnosis  ;  Course  of  the  Disease  ; 

Prognosis          754 

Chapter       V.  General  Treatment  of  Insanity 758 

Treatment  of  Acute  Cases 763^ 

Chapter      VI.  Mania 772 

Chapter    VII.  Melancholia 778 

Chapter  VIII.  Circular  Insanity .  789 

Chapter     IX.  Epileptic  Insanity      794 

Chapter       X.  Dementia 802 

Secondary  Dementia      803 

Senile  Dementia 804 

Primary  Dementia 806 

Chapter     XI.  Paralytic  Dementia 808 

Chapter    XII.  Paranoia 821 

Chapter  XIII.  Idiocy 845 


INDEX 895 


NERVOUS  DISEASES 

BY 

ARCHIBALD  CHURCH,  M.  D. 


NERVOUS  DISEASES. 


PART  I. 

EXAMINATION  OF  PATIENTS. 


CHAPTER  I. 
THE  ANAMNESIS. 

Diagnostic  investigation  in  neuroloo-ical  work  is  a  fine  art.  A 
correct  opinion  depends  upon  it.  It  is  the  first  step  toward  treatment, 
the  legitimate  end  of  medicine.  The  physician  is  dealing  with  morbid 
conditions,  revealing  themselves  for  the  most  part  by  functional  errors. 
The  large  subjective  side  of  the  problem,  with  the  unreliability  of  the 
patient's  responses,  adds  to  the  difficulty  and  calls  for  keenness  of  judg- 
ment at  every  step.  The  use  of  several  tests  for  determining  a  given 
state  is  of  much  importance,  especially  in  conditions  that  are  not 
objectively  evident.  By  comparison  of  the  results  thus  obtained,  and 
sometimes  by  striking  an  average  of  such  results,  exactness  may  be 
approximately  reached,  while  dependence  upon  any  one  of  them  might 
be  misleading. 

On  the  other  hand,  by  the  use  of  instruments  of  precision,  controlled 
by  anatomical  and  physiological  rules,  a  definiteness  can  often  be  reached 
in  nervous  diseases  not  elsewhere  possible.  Localization  in  brain 
and  cord  lesions  is  sometimes  exact  to  a  degree,  and  prognosis  is  often 
absolutely  clear.  But  in  many  instances  of  the  so-called  functional 
diseases,  careful  study,  the  shrewdest  judgment,  and  a  wide  experience 
enable  one  only  approximately  to  appreciate  the  situation.  The  entire 
data  can  be  secured  only  by  a  systematic  and  frequently  prolonged  or 
often-repeated  examination,  and  it  is  of  the  first  importance  that  the 
medical  man  should  maintain  an  entirely  judicial  and  non-committal 
mental  attitude  toward  his  patient  and  the  diagnosis  until  he  has  every 
available  fact  at  his  disposal.  Snap-shot  diagnoses  may  be  gratifying 
to  all  concerned,  if  correct,  but  they  are  very  likely  to  be  wrong  and 
prejudicial  to  a  proper  subsequent  estimation  of  the  case  and  are  never 
necessary. 

A  systematic  examination  can  not  be  made  without  a  prearranged 
formula.  The  nearer  this  corresponds  to  the  development  of  the 
case,  the  less  likely  are  important  matters  to  be  overlooked.  It 
therefore  should  be  chronological.  Most  patients  insist  on  tellmg  their 
own  stories  in  their  own  way.  It  is  sometimes  well,  especially  in 
private  practice,  to  allow  them  to  do  so,  and  when  they  finish,  to  begin 
2  17 


18  NERVOUS  AND   MENTAL  DISEASES. 

properly.  In  nervous  diseases  the  family  history  is  often  of  paramount 
importance.  Taken  with  the  appearance  of  the  patient,  it  gives  valu- 
able indications  as  to  the  constitutional  make-up  of  the  individual. 
The  family  history,  then,  is  to  be  investigated  first,  after  noting 
the  name,  age,  sex,  nationality,  occupation,  and  social  state  of  the 
patient. 

Neurotic  Heredity. — In  seeking  information  regarding  the  ante- 
cedents of  a  patient,  much  tact  must  sometimes  be  employed.  Patients 
are  loath  to  detail  matters  of  this  character,  not  always  from  a  wish  to 
conceal  them,  but  from  disinclmation  to  admit  even  to  themselves  any 
serious  shortcoming  or  morbidity.  To  the  half  that  is  directly  learned 
an  equal  amount  may  sometimes  be  reasonably  added.  Much  can  be 
learned  by  interrogating  other  members  of  the  family,  especially  if 
related  by  marriage,  the  family  physician,  and  old  acquaintances,  but 
the  confidence  and  rights  of  the  patient  must  not  be  forgotten.  Nor  is 
it  sufficient  to  seek  for  instances  of  the  identical  disease  in  the  family 
history  of  the  case.  The  significant  factor  is  a  neuropathic  liability, 
and  this  is  indicated  with  more  or  less  force  by  the  appearance  of  ner- 
vous and  mental  diseases  of  any  sort,  of  slight  or  serious  degree,  in  the 
ascendants.  For  instance,  a  hysterical  mother  has  an  epileptic  child 
and  an  idiotic  grandchild  ;  or  highly  wrought  nervous  organizations  in 
mother  and  father  eventuate  in  neurasthenic  and  unstable  children. 
Atavism  in  mental  and  nervous  diseases  is  quite  common.  Insanity  in 
the  same  or  neighboring  generations  may  alternate  with  neuroses  or 
mild  psychoses,  and  any  combination  may  exist.  Consanguinity  on  the 
part  of  parents,  in  addition  to  furnishing  a  tendency  to  infecundity,  is 
likely  to  bring  together  the  subjects  of  similar  neurotic  taints,  which 
are  thereby  reinforced  in  the  offspring.  In  itself,  however,  consanguinity 
has  probably  been  overestimated  as  a  causal  factor  in  nervous  and 
mental  diseases.  The  association  of  crime,  precocity,  genius,  neuroses, 
and  psychoses  in  related  individuals  may  be  encountered.  Certain 
nervous  diseases  are  of  direct  hereditary  character,  being  transmitted 
from  generation  to  generation  or  appearing  in  a  group  of  cases  in  a 
given  generation.  It  is  only  needful  to  mention  Friedreich's  ataxia 
and  Huntingdon's  chorea,  but  tabes  dorsalis,  paralysis  agitans,  multiple 
sclerosis,  muscular  atrophies,  and  practically  every  organic  and  functional 
nervous  disease  occasionally  presents  family  groups  of  this  nature.  ^ 
Many  of  the  familial  diseases  which  have  been  described  as  essentially 
distinct  are  found  to  insensibly  merge  through  the  observation  of  inter- 
mediate cases;  and  Baumlin^  contends  that  all  typical  diseases  of  a 
familial  character  drift  into  each  other  through  such  connecting  links. 
A  family  constitutional  defect  is  the  only  essential  feature. 

Debilitating  diseases,  like  tuberculosis,  rheumatism,  and  gout,  are 
significant.  Indeed,  Charcot  was  inclined  to  consider  arthritism  as  a 
congener  of  nervous  diseases.  Inherited  syphilis  is  on  an  entirely 
diiferent  footing.      Not  only  is  it  cajiable  of  producing  embryological 

^  Ch.  Fere,  "  La  Famille  Nevropathique, "  Paris,  1894. 
2  "Deut.  Zeit.  f.  Nervenheilk.,"  Oct.,  1901. 


THE  ANAMNESIS.  19 

defects,  but  its  blight  may  make  itself  evident  on  the  part  of  the 
nervous  apparatus  during  the  period  of  growth  or  in  adult  life,  modify- 
ing cerebral  or  spinal  functions  and  at  times  leading  to  histological 
changes  in  the  central  and  peripheral  parts,  which  may  vary  in  degree 
up  to  destructive  lesions.  Diabetes  and  Brighfs  disease  are  very  com- 
mon in  neurotic  families. 

Personal  History. — The  investigator  should  go  most  carefully  into 
the  medical  life-history  of  his  patient.  While  doing  so,  indeed,  when- 
ever opportunity  offers,  the  conduct,  attitude,  manner,  gait,  j^osture, 
complexion,  expression,  gestures,  and  individuality  of  the  person  should  be 
keenly  watched.  This  observation  becomes  in  time  a  trained,  almost 
automatic,  faculty,  so  that  minute  details  subconsciously  apprehended  at 
the  time  can  be  readily  recalled. 

In  infancy,  was  there  any  birth  difficulty,  possible  brain  or  spinal 
injury  from  protracted  labor,  precipitate  labor,  or  instrumentation ;  lack 
of  vigor,  suspicion  of  syphilis,  or  convulsions  ?  During  childhood,  did 
the  patient  present  any  nervous  phenomena,  such  as  marked  delirium  or 
spasms  under  febrile  conditions  or  from  irritation  of  the  gums  and  in- 
testinal tract?  Was  there  enuresis,  chorea,  somnambulism,  or  night- 
terrors  ?  Was  he  precocious  or  otherwise,  docile  or  obstinate,  cheerful 
or  morose,  forward  or  retiring  ?  At  pubescence,  were  there  mental 
changes  of  unusual  character,  moodiness,  expansiveness,  cruelty  ?  Was 
the  establishment  of  menstruation  attended  by  pain  or  hysterical  mani- 
festations ?  Was  masturbation  indulged  in  or  suspected  ?  During  adoles- 
cence, what  was  the  career,  relation  to  the  opposite  sex,  success  in  school 
and  business,  and  what  has  been  the  course  of  events  through  adult  life  ? 

The  past  illnesses  of  the  patient  should  then  receive  attention  in 
the  same  systematic  manner.  The  fevers  and  febricula  of  childhood, 
the  exanthemata  and  infections.  The  diseases  of  the  nasopharynx, 
stomach,  intestines,  and  rectum,  of  the  lungs  and  heart,  of  the  skin,  the 
special  disorders  of  chest,  abdomen,  pelvis,  and  genito-urinary  apparatus 
must  not  escape  attention.  Especial  inquiry  should  be  made  for  rheu- 
matism, gout,  grip,  and  malaria.  The  venereal  history  of  the  patient  and 
the  possibility  of  specific  infection  should  in  every  case  be  carefully 
inquired  into.  This  is  a  rule  that  has  no  exceptions.  The  investiga- 
tion must  be  modified  and  guarded  according  to  individual  circum- 
stances, but  nothing  should  deter  the  physician  from  making  sure  that 
a  factor  of  this  sort  is  not  overlooked.  If  injuries  have  been  received, 
what  were  their  character  and  consequences?  Regarding  habits,  it  is 
to  be  borne  in  mind  that  neurotic  people  are  especially  liable  to  carry 
everything  to  extremes  and  are  prone  to  become  the  abject  subjects 
of  some  perverted  practice  or  stimulant  addiction.  Masturbation  and 
venery  take  firm  hold  on  them.  Tobacco,  alcohol,  morphin,  cocain, 
chloral,  and  even  tea  and  coffee  master  them  completely.  These  in 
turn  often  break  down  the  moral  status  of  the  individual  and  make 
him  unreliable  and  untruthful.  Only  inadvertently  or  at  second 
hand  does  the  physician  sometimes  gain  the  required  information,  but 
justifiable  suspicion  once  aroused,  he  can  usually  go  to  the  root  of  the 
matter. 


20  NERVOUS  AND  MENTAL  DISEASES. 

In  neurasthenic,  hypochondriac,  and  hysterical  cases  frequently  the 
patient  has  most  seriously  overestimated  some  such  habit,  is  morbidly 
apprehensive  as  to  its  results,  exaggerates  its  every  relation,  and  the 
entire  life  seems  to  revolve  around  this  central  erroneous  idea.  One 
must  avoid  being  led  by  such  unfortunates  into  adopting  their  point  of 
view.  The  details,  duration,  and  probable  effect  of  the  Jiabit  being 
clearly  understood,  its  morbific  influence  can  be  properly  estimated. 
Let  it  never  be  forgotten  that  many  of  these  habits  are  symptoms,  not 
causes,  of  nervous  disturbance,  and  are  the  result  of  an  underlying 
predisposition  upon  which  they  are  grafted.  There  they  take  on  a 
morbid  development  and,  in  turn,  no  doubt,  add  to  the  unbalance  of  the 
individual. 

The  residence  or  habitat  of  the  patient  is  an  important  consid- 
eration. It  calls  attention  to  the  climatic  and  local  conditions  favoring 
health  or  disease.  Unhealthful  surroundings  are  of  immediate  concern, 
and  throw  a  strong  light  uj)on  the  causation  of  many  nervous  disorders. 

Occupation. — Many  occupations  predispose  to  nervous  maladies 
and  sometimes  furnish  the  cause.  Indeed,  a  group  of  diseases  is  known 
as  occupation  neuroses,  of  which  writers'  cramp  is  a  type.  Workers  in 
metals,  particularly  those  handling  lead,  phosphorus,  mercury,  and 
arsenic  ;  people  subjected  to  illuminating  gases  or  bisulphid  of  carbon, 
and  those  who  deal  in  alcoholics,  and  who  are  thereby  likely  to  over- 
indulge, are  subject  to  neuritides  and  associated  mental  disturbances. 
Work  requiring  exposure  to  cold  and  conditions  favoring  rheumatic 
processes  entail  a  tendency  to  cerebral  arterial  mischief  and  peripheral 
palsies.  Divers  and  those  working  in  caissons,  or  elsewhere,  under 
increased  atmospheric  pressure  frequently  present  spinal  lesions  with 
paraplegic  symptoms.  Occupations  which  demand  constant  mental 
strain  and  sedentary  habits,  as  in  speculative  mercantile  life,  teaching, 
and  some  of  the  professions,  furnish  large  numbers  of  neurasthenics. 
On  the  other  hand,  the  unoccupied  are  likely  to  become  selfish,  intros- 
pective, hysterical,  and  hypochondriac. 

The  Illness. — From  the  patient's  statement,  his  personal  history, 
and  the  physician's  observation,  the  noting  of  the  details  of  the  illness 
under  consideration  is  often  a  simple  matter.  The  medical  man  from 
his  special  knowledge  must  supplement  the  impressions  of  the  layman. 
In  the  "  rheumatism"  preceding  ataxia  he  discerns  initial  features  of 
tabes,  and  in  some  long-antecedent  moral  shock  he  recognizes  the  origin 
of  the  fixed  hysterical  idea  that  may  have  eventuated  in  a  contracture. 
For  each  major  group  of  nervous  maladies,  psychic,  cerebral,  spinal, 
and  peripheral,  he  must  follow  out  the  clues  his  training  recognizes  or 
his  studies  and  experience  suggest. 

Beginning  with  initial  symptoms  and  alleged,  suspected,  or  positively 
known  causal  conditions,  the  manifestations  of  the  disease  are  to  be 
systematically,  briefly,  and  clearly  developed  and  noted,  with  full  atten- 
tion to  remissions,  intermissions,  or  relapses.  In  convulsive  disorders  a 
full  clinical  investigation  of  the  attack  is  of  prime  importance.  It 
should  embrace  its  exciting  cause,  onset,  features  of  consciousness, 
motor    signs    and    phenomena,    attitudes,    duration,    termination,    and 


THE  ANAMNESIS.  21 

sequelae.  In  sensory  disturbances  investigate  the  particular  dyses- 
thesia or  pain,  its  onset,  exact  location,  intensity,  duration,  and  associated 
conditions.  In  paralytic  maladies  determine  the  mode  of  onset,  exact 
distribution,  and  the  character  and  degree  of  motor  failure.  The  mental 
symptoms  are  to  be  noted  with  equal  care,  attention  being  directed  to 
their  fixity,  emotional  character,  and  reasonableness  or  complete  oppo- 
sition to  facts  within  the  patient's  range  of  knowledge.  An  important 
question  is  whether  the  patient  can  correct  his  morbid  ideas  by  mental 
effort  or  is  entirely  subjugated  by  his  delusional  states.  Finally,  the 
tendency  to  improvement  or  the  reverse  should  be  indicated. 

Physiognomy  of  the  Patient. — Formerly  it  was  considered  suf- 
ficient to  describe  a  patient  as  of  the  nervous,  lymphatic,  or  sanguine 
temperament,  and  this  has  a  certain  value,  but  a  better  conception  of 
the  physical  status  is  to  be  had  from  a  study  of  the  physiognomy  of  the 
individual.  Based  upon  embryological  conditions  and  formulated  with 
some  precision  by  Lombroso,  Dejerine,  Weismann,  Fere,  and  others, 
we  can  recognize  a  type  of  degenerate  or,  preferably,  defective  individ- 
uals, from  whom  are  largely  recruited  the  neurotic,  the  insane,  and  the 
criminal  classes. 

The  marks  of  this  type  are  called  the  stigmata  of  degeneracy,  and 
may  be  divided  into  the  morphological  and  the  functional. 

Morphological  Stigrtiata. — Commencing  at  the  crown  of  the  head, 
the  whorl  of  hair  at  the  vertex  which  normally  is  close  to  the  median 
line  may  be  widely  displaced  or  duplicated.  The  eranial  conformation 
is  often  abnormal  in  outline,  capacity,  or  dimensions.  The  occipital 
protuberance  and  ridges,  the  frontal  eminences,  and  the  mastoid  processes 
are  usually  excessively  developed.  The  facial  angle  is  reduced,  the 
contour  of  the /ace  asymmetrical,  the  lower  jaw  disproportionately  large 
and  prognathic.  The  hard  palate  is  sharply  vaulted,  the  dental  arcades 
narrow,  disproportionate,  saddle-shaped,  or  angular  and  badly  articulated  ; 
the  teeth  defective,  misplaced,  with  sometimes  persistence  of  milk-teeth 
late  in  life.  The  ears  are  disproportionate  in  size,  misplaced,  mal- 
formed, particularly  at  the  root  of  the  helix,  which  may  bifurcate,  or 
the  tragus  and  antitragus  are  misplaced,  while  the  concha  is  crumpled 
or  has  a  tendency  to  stand  out  widely  from  the  head.  The  eyes  sliow 
notable  defects,  extreme  refraction  anomalies,  squints,  different  colored 
irides,  and  disproportionate  lids  and  palpebral  openings.  Deviation  of  the 
nose,  septal  deformities,  harelip,  cleft  palate,  and  remnants  of  bi-anchial 
clefts  in  the  neck  or  in  front  of  the  ears,  and  the  presence  of  other  tera- 
tological  deficiencies  are  frequent  in  this  class  of  persons. 

On  the  part  of  the  trunk,  spina  bifida,  sacral  growths  of  hair,  deep 
sternal  furrows  and  concavities,  or  disproportion  between  thorax  and 
abdomen  are  to  be  noted. 

The  Extremities. — The  upper  and  lower  limbs  may  be  disproportioned 
to  each  other  or  to  the  trunk.  They  may  be  mismated  in  length  and 
development.  The  hands  and/ee^  may  be  too  small  or  too  large.  There 
is  often  a  tendency  to  left-handedness  and  left-sided  overdevelopment. 
Deformities  of  the  fingers,  such  as  syndactyly,  Polydactyly,  deviations, 
distortions,  excessive  length  or  shortness,  especially  undersize  of  the 


22  NERVOUS  AND  3IENTAL  DISEASES. 

ring  and  little  fingers  as  compared  with  the  rest  of  the  hand,  are 
common  in  degenerates. 

The  genitalia  in  the  male,  besides  a  general  lack  of  growth,  are  fre- 
quently developmentally  defective,  presenting  hypospadias,  epispadias, 
extrophy  of  the  bladder,  cryptorchidism,  congenital  phimosis,  scrotal 
fissure,  etc.;  while  in  the  female,  imperforate  hymen,  double  vagina  and 
uterus,  and  hypertrophied  clitoris  and  labia  are  not  rare. 

Taken  as  a  whole,  the  degenerate  physique  is  often  marked  by  a 
diminished  stature  and  an  inferior  vigor.  Many  neurotic  males  present 
the  general  body  conformation  of  the  opposite  sex,  including  sloping, 
narrow  shoulders,  wide  hips,  excessive  pectoral  and  pubic  adipose 
deposits,  with  a  lack  of  masculine  hirsute  and  muscular  marking.  The 
female  may  present  masculine  characteristics,  and  in  each  case  the 
opposite  sexuality  may  be  further  manifest  in  the  actions,  dress,  man- 
ners, voice,  and  mental  qualities  of  the  individual.  Both  sexes  may 
retain  the  physical  attributes  of  childhood, — infantilism, — and  in  these 
cases  the  mental  development  is  always  retarded. 

On  the  part  of  the  skin,  albinism,  melanism,  and  multiple  nevi  are 
sometimes  degenerate  accompaniments.  A  general  lack  of  thorough 
development  in  the  dermal  structures  is  manifested  by  defective  hair 
and  nails  and  simplicity  in  the  papillary  lines  of  the  finger-tips. 

The  functional  stig-mata  of  degeneracy  show  themselves:  (1) 
Mentally,  in  defective  mind  qualities.  These  vary  in  degree  from  idiocy 
to  simple  retardation  of  speech  development,  in  aberrant  mental  and 
moral  tendencies,  among  which  may  be  enumerated  destructiveness, 
wilfulness,  indecency,  deceit,  and  sometimes  extreme  acuteness  and 
even  precocity  in  limited  fields.  Genius  is  essentially  abnormal  how- 
ever valuable  it  may  be  to  the  individual  and  to  the  race.  It  is  often 
attended  by  many  of  the  physical  stigmata  of  defect. 

(2)  Physically,  may  be  mentioned  backwardness  in  walking,  stam- 
mering, incontinence  of  urine,  merycism,  color-blindness,  deaf-mutism, 
perverted  tastes,  and  cravings  leading  to  alcoholism  and  other  stimulant 
addictions.  Perversions  of  the  genesic  sense,  marked  by  sexual  crimes 
and  debasing  practices,  are  also  common.  Degenerates  have  frequently 
a  lack  of  adaptability  to  their  environment,  and  so  more  or  less  strongly 
depart  from  the  type  and  tend  to  extinction,  subjugated  by  the  law  of 
survival  of  the  fittest. 

In  estimating  the  various  marks  of  degeneracy  it  is  clear  that  very 
few  of  them,  taken  alone,  are  sufficient  to  enable  the  classification  of 
their  possessor  among  the  defectives,  and  that  a  very  great  many  of  the 
minor  stigmata  may  be  present  in  a  given  case,  associated  Avith  strong 
mental,  moral,  and  physical  attributes.  All  of  them,  from  cleft  palate 
to  moral  imbecility,  are  referable  to  defective  development.  In  the 
presence  of  numerous  indications  of  physical  defect  we  are  entitled  to 
expect  the  association  of  their  mental  and  neural  analogues.  Hence 
their  importance  to  the  neurologist. 

The  mental  condition  of  the  patient  should  not  be  overlooked. 
DisturVjances  in  the  psychic  sphere  are  very  common  in  nervous  dis- 
orders and  often  overshadow  them.      Persistent  depression  or  excitement 


THE  GENERAL  PHYSICAL  EXA^IINATION.  23 

out  of  proportion  to  their  causes,  and  delusions  and  haUucinations  that 
may  or  may  not  be  properly  recognized  and  corrected  by  the  patient, 
require  close  scrutiny.  Especially  in  hysteria  are  we  confronted  by  a 
train  of  mental  symptoms,  attitudes,  aud  reactions  that  may  easily  be 
confounded  with  insanity  or  which  actually  carry  the  patient  over  the 
rather  broad,  dividing  neutral  ground  into  the  realm  of  alienism.  Loss 
of  self-control,  irritability,  increased  emotionalism,  and  vague  or  formulated 
apprehensions  are  the  ordinary  concomitants  of  neurasthenia.  Many 
cerebral  diseases  produce  unconsciousness. 

Sleep  in  nervous  patients  is  one  of  the  most  important  practical 
considerations.  If  it  is  disturbed,  seek  the  cause,  remembering  that 
habits  of  wakefulness  are  easily  formed.  Distressing,  formulated,  and 
repeated  dreams  and  nightmares  are  the  neurasthenic's  portion  and  the 
expression  of  his  lowered  nervous  and  physical  tone.  Somnambulism, 
nocturnal  urinary  incontinence  and  night-terrors  are  the  common 
property  of  nervous  individuals  in  childhood.  Some  patients  find 
difficulty  in  falling  asleep,  others  in  remaining  asleep;  others  are 
simply  unrefreshed  upon  awaking.  The  selection  of  soporific  remedies 
and  the  time  of  their  exhibition  turn  upon  such  considerations. 

Memory. — Nearly  every  nervous  invalid  asserts  a  loss  of  memoiy, 
which  rarely,  however,  exists.  This  mental  faculty  varies  not  only 
greatly  in  individuals,  but  is  subject  to  great  modifications  in  a  given 
individual  under  different  conditions  of  health  and  age.  To  the 
keen  perceptions  of  a  child  everything  is  novel,  is  deeply  imprinted 
in  the  mind,  and  is  rarely  forgotten.  Later  in  life  a  new  face  or  name 
is  no  rarity,  is  not  sharply  apprehended,  and  its  recollection  is  conse- 
quently difficult  or  impossible.  The  old,  in  part  for  this  reason,  re- 
member their  early  experiences  better  than  more  recent  happenings. 
In  physical  ill-health  and  in  conditions  of  mental  abstraction  or  intro- 
spection, as  in  hypochondria,  hysteria,  and  neurasthenia,  the  alleged 
loss  is  really  a  lack  of  the  mental  concentration  that  constitutes  the 
essential  basis  for  good  memory.  In  such  cases  this  may  be  demon- 
strated by  a  few  questions  on  remote  personal  happenings,  which  will 
usually  be  recited  with  extreme  minuteness  and  detail. 


CHAPTER  II. 
TEE  GENERAL  PHYSICAL  EXAMINATION. 

Present  Condition. — What  has  gone  before  prepares  the  way  for 
a  thorough  physical  examination.  Whenever  possible,  the  clothing  of 
the  patient  should  be  entirely  removed,  as  study  of  the  physical  human 
outlines  is  most  valuable.  Without  this  step  spinal  deviations,  chest 
deformities,  lack  of  symmetry  in  the  limbs,  or  other  serious  defects  of 
the  most  important  diagnostic  character  may  escape  notice.  UpoE 
sketch  outlines  of  the  human  figure  supplied  in  text-books  and  by 
dealers  abnormalities  of  form  and  function  may  be  indicated  with  pre- 
cision.    No  lesion  is  too  slight  to  be  overlooked,   and  no  assertion  of 


24  NERVOUS  AND  MENTAL  DISEASES. 

functional  health  is  to  go  unquestioned.  Remote  conditions  are  not 
infrequently  causal  of  central  disturbance,  and  central  mischief  is  mani- 
fested by  peripheral  states.  The  nutritive  process  may  first  engage 
attention. 

The  Alimentary  Tract. — The  condition  of  the  teeth  in  relation  to 
mastication  and  abnormalities  of  position  or  evidence  of  inherited 
syphilis,  the  color  of  the  gums  with  reference  to  anemia  or  evidences  of 
metallic  poisoning,  such  as  the  blue  line  of  lead  and  the  sponginess  of 
mercury  and  phosphorus,  can  be  noted  at  a  glance.  Particular  atten- 
tion is  to  be  directed  to  the  tongue.  Aside  from  indicating  the  state 
of  the  stomach,  it  may  give  important  evidence  of  nervous  diseases. 
The  fine  fibrillar  twitching  of  general  paresis  and  bulbar  palsy,  the 
tremor  of  alcoholism,  the  contortions  of  chorea,  the  lack  of  motility  and 
atrophy  in  labioglossolaryngeal  paralysis,  and  the  deviation  on  protru- 
sion in  hemiplegia  are  positive  signs  of  great  value.  Abnormalities  of 
appetite  for  food,  gastric  and  intestinal  indigestion,  constipation,  and  rectal 
conditions  are  significant  in  many  ways.  Attacks  of  colic,  vomiting,  diar- 
rhea, and  rectal  tenesmus  have  special  blearing  on  the  condition  of  the 
reflex  spinal  centers.  The  condition  of  spleen  and  liver,  as  in  acute  and 
malarial  infections  and  chronic  alcoholism,  may  give  important  indi- 
cations of  constitutional  and  local  states  that  have  a  relation  to  the 
nervous  phenomena  under  investigation. 

The  Respiratory  Organs. — In  the  nasal  and  pharyngeal  spaces 
inflammations,  new  growths,  or  irritation  zones  may  furnish  the  starting- 
point  for  neurotic  states  of  the  most  varying  nature,  as  hysterical  sneezing, 
spasmodic  asthma,  and  pronounced  neurasthenia.  Laryngeal  jjalsies  and 
spasms  require  a  careful  topical  examination.  In  the  condition  of  the 
lungs  and  pleurce  we  seek  for  local  explanation  of  various  symptoms, 
such  as  respiratory  pain  and  oppression,  costal  neuralgia,  continuous 
cough,  or  for  the  evidence  of  tubercular  deposits,  explanatory,  perchance, 
of  a  cachexia  that  might  otherwise  be  erroneously  referred  to  nervous 
depression. 

Circulatory  Apparatus. — The  condition  of  the  heat^t  is  revealed 
only  by  a  thorough  physical  examination  of  its  position,  size,  action,  and 
valvular  competency.  The  condition  of  the  arteries,  patent  to  the  eye 
in  a  tortuous  temporal,  to  the  finger  by  radial  atheroma,  should  be  still 
more  extensively  investigated  in  the  femoral,  brachial,  carotid,  and  other 
superficial  regions.  The  condition  of  the  blood-pjressure,  as  shown  by 
arterial  tension,  on  the  two  sides  of  the  body,  near  the  heart,  and  at  a 
distance,  is  worthy  of  careful  study.  It  enables  one  to  draw  analogical 
conclusions  as  to  the  circulatory  apparatus  of  the  central  nerve-organs. 
The  condition  of  the  arteries  is  the  best  index  of  the  real  age  of  an 
individual.  In  them  we  often  find  evidence  of  a  premature  decay  out  of 
all  relation  to  the  years  that  have  been  lived.  Sphygmographic  tracings, 
as  a  method  of  record  and  precision,  have  their  own  value.  The  pidse, 
by  its  lack  of  rhythm,  particularly  by  a  tendency  to  great  variation  in 
its  rate,  depending  upon  slight  exciting  causes,  often  shows  the  unstable 
nerve-tone  of  the  patient,  or  a  general  asthenia.  Flushings,  mottlings, 
local  anemias  and  edemas  ai'e  vivid  expressions  of  angioneurotic  disturb- 
ances.     The   blood  must  be  examined  for  parasites,   hemoglobin,   and 


TEE  GENERAL  PHYSICAL  EXAMINATION.  25 

corpuscular  conditions.     The  severe  anemias   have   a   very   important 
relation  to  brain  and  spinal  symptoms. 

The  temperature  may  be  greatly  modified  by  nervous  diseases. 
Organic  brain-lesions  may  upset  the  balance  between  the  thermotaxic 
and  thermogenic  centers,  producing  either  a  very  high  or  a  markedly 
subnormal  body-heat.  In  hysteria  a  very  high  range  of  temperature  is 
sometimes  noted  without  the  usual  concomitants  of  fever.  In  cerebral 
hemorrhage  and  basilar  meningitis  the  temperature  is  often  below  the 
normal.  Early  in  cerebral  hemorrhage  the  paralyzed  side  presents 
usually  a  disproportionate  elevation  of  a  degree  or  more  of  heat  over  the 
opposite  half  of  the  body,  as  is  shown  by  axillary  temperatures.  The 
temperature  of  the  paralyzed  side  later  becomes  subnormal.  Slight 
variations  of  the  central  normal  temperature,  usually  in  an  upward 
direction,  are  frequently  observed  in  pure  neurasthenic  states,  while  the 
extremities  are  commonly  cold. 

The  Integument. — From  the  appearance  and  condition  of  the  cuta- 
neous expanse  much  is  to  be  learned  as  to  the  general  health  of  the 
individual  and  the  activity  of  his  physical  functions.  The  skin  may 
be  greatly  modified  by  nervous  maladies.  In  some  instances  the 
dermal  manifestations  make  up  the  major  part  of  the  disease,  or  the 
dermatosis  may  be  an  associated  feature  of  other  neurotic  disturbance. 
All  varieties  of  urticaria  are  of  frequent  occurrence  among  the  neurotic. 
Dermographia  and  the  tache  cerebrale  of  meningitis  demonstrate  the 
vasomotor  irregularities.  Herpes  and  morphea,  limited  to  the  anatom- 
ical distribution  of  nerves  or  spinal  segments,  as  in  zoster  on  the  face, 
trunk,  or  limbs,  declare  the  nervous  involvement.  Neuralgias  of 
long  standing  are  frequently  marked  by  dermal  changes  of  increased 
or  decreased  nutrition,  as  witness  the  thickening  of  the  skin  of  the 
face  in  neuralgia  of  the  fifth  cranial  nerve  and  the  subsequent  blanch- 
ing or  the  actual  loss  of  the  eyebrow  and  hair.  The  neuritides,  if 
of  a  severe  grade,  show  dermal  dystrophy  as  well  as  muscular  wast- 
ing. The  epithelial  structures  involved  may  take  on  increased  growth 
if  vascular  sta.sis  favor  increased  nutrition,  giving  rise  to  scaliness 
of  the  skin  and  increased  growth  of  the  hair  and  nails.  More  fre- 
quently atrophic  changes  follow ;  the  skin  is  thinned  and  glazed,  the 
epithelium  scant  and  poorly  protective  of  the  more  highly  organized 
subjacent  tissue.  The  hair  becomes  dry,  brittle,  and  sparse,  and  the 
nails  rough-ridged  and  sometimes  covered  with  overlapping  scales. 
Pigmentary  changes,  swelling,  and  blue  edema  are  not  infrequent  in 
hysteria.  The  enormous  thickenings  in  myxedema  and  acromegalia  are 
also  due  to  perverted  trophic  control. 

Genito-urinary  Tract. — In  the  genito-urinary  tract  are  found 
many  conditions  bearing  an  intimate  relation,  both  causal  and  sympto- 
matic, to  nervous  diseases.  Some  of  them  are  overlooked  or  unknown 
to  the  patient,  and  others  receive  altogether  too  much  attention  at  his 
hands.  A  thorough  clinical  examination  of  the  urine,  which  should  be 
quantitative  as  well  as  merely  qualitative,  is  best  made  from  a  sample 
of  a  carefully  measured  twenty-four-hour  collection.  It  shows  at  once 
the  eliminative  powers  of  the  organism  through  the  important  excretion 
outlet  of  the  kidneys.     A  lessened  output  of  urea,  or  the  presence  of 


26  NERVOUS  AND  MENTAL  DISEASES. 

albumin  or  sugar,  give  important  data  as  to  the  blood-state  and  may- 
explain  grave  cerebral  manifestations,  such  as  convulsions  and  coma.  A 
very  low  specific  gravity  is  noted  after  hysterical  attacks.  A  large  quan- 
tity of  phosphates  and  oxalates  is  common  to  many  neurasthenic  condi- 
tions, and  an  ammoniacal  urine  is  usual  in  paretic  states  of  the  detrusor 
urinse.  After  an  epileptic  attack  the  specific  gravity  and  solid  con- 
stituents of  the  urine  are  increased. 

The  microscope,  besides  giving  evidence  of  organic  disease,  such  as 
nephritis,  pyelitis,  and  cystitis,  may  show  spermatozoa  from  a  relaxed 
control  of  the  outlets  of  the  seminal  vesicles,  but  more  often  demon- 
strates that  the  deposit  considered  seminal  by  the  patient  is  devoid  of 
testicular  products. 

Anuria  in  nephritis  is  of  most  serious  import,  though  it  may  exist 
almost  indefinitely  in  hysteria  when  associated  with  persistent  emesis, 
whereby  the  uric  products  are  vicariously  ejected. 

The  state  of  the  kidneys  and  weters  is  made  out  largely  by  the 
investigation  of  the  urinary  secretion,  but  the  bladder  is  open  to  more 
proximate  methods.  Its  size,  expulsive  and  retentive  powers,  its  con- 
tents, and  the  condition  of  its  mucous  lining  are,  in  suitable  cases,  to  be 
investigated  with  precision.  Loss  of  sphincteric  control  of  the  bladder  in 
paraplegic  and  ataxic  conditions  is  usual,  while  in  meningitis,  and  in 
comatose  states  generally,  retention  of  urine  is  to  be  expected  and  pro- 
vided for. 

The  externcd  genitals  rarely  give  much  information.  In  vadles,  preputial 
adJiesions  and  accumulations  or  a  long  phimotic  prepuce  may  be  the 
source  of  irritation  and  the  inciting  cause  of  general  nervous  phenomena. 
Here,  as  elsewhere,  any  abnormal  and  correctable  state  should  not  escape 
appropriate  attention.  This  is  emphatically  true  of  the  deepei^-lying 
generative  organs  in  the  female.  Undoubtedly  undue  importance  has 
attached  to  them  and  much  ill-advised  meddling  has  been  bestowed,  but 
a  lack  of  integrity  on  their  part  should  certainly  engage  methodical 
treatment. 

The  genesic  sense  is  usually  blunted  or  completely  destroyed  in  ad- 
vanced locomotor  ataxia  and  spinal  lesions  which  cut  off  peripheral 
sensation.  It  is  reduced  in  all  depressed  physical  states,  whether  asso- 
ciated with  marked  nervous  phenomena  or  not.  On  the  other  hand,  the 
genital  reflex  may  be  accentuated  in  lateral  sclerosis  of  the  cord,  and 
priapism,  unattended  by  increased  desire,  may  be  a  troublesome  feature. 
In  injuries  to  the  cervical  portion  of  the  cord,  priapism  is  likewise 
common. 

The  question  of  sexual  irritation  and  overindulgence  calls  for  more 
than  ordinary  thought.  Excess  is  a  matter  purely  relative  to  the  indi- 
vidual and  his  condition  at  the  time  of  indulgence.  Overuse  of  any 
organic  function  is  shown  by  persistent  fatigue  and  irritable  prostration. 
This  may  here  furnish  us  a  working  criterion,  but  we  are  to  remember 
that  matters  have  already  gone  too  far  when  the  great  margin  of  natural 
reserve  power  has  been  overdrawn  and  even  temporary  debility  pro- 
duced. Thus,  an  amount  of  masturbation  or  sexual  indulgence  insig- 
nificant in  a  sturdy  individual,  is  sufficient  in  the  defective  neurotic  to 
induce  a  profound  depression. 


THE  MUSCULAR  SYSTEM. 


27 


CHAPTER  III. 
THE  MUSCULAR  SYSTEM. 

Motility. — It  is  a  rule  with  hardly  an  exception  that  nervous 
disorders  are  marked  by  errors  of  motility.  These  vary  from  a  condition 
of  slight  general  weakness,  or  jparesis,  to  complete  loss  of  muscular 
power,  or  ijaralysis,  from  slight  tremor  to  rigid  contractions.  The 
character  and  distribution  of  the  muscular  difficulty  is  often  of  the  first 
importance  in  diagnosis  and  in  localizing  limited  lesions. 

The  station,  attitude,  and  gait  of  the  patient,  depending  as  they  do 
largely  on  muscular  force,  control,  and  activity,  often  furnish  most 
important  information.  The  contractured,  semiflexed  position  of  the 
upper  extremity  and  the  rigid  lower  limb,  swung  en  masse  from  the 
pelvis  with  dragging  toe,  mark  the  hemiplegic.     The  bowed  and  trotting 


Fig.  1. — Mathieu's  hand-dynamometer  fitted  with  detachable  handles. 


gait  of  paralysis  agitans  ;  the  stamping  and  sprawling  of  tabes  dorsalis  ; 
the  steppage  or  high  knee-action  with  dangling  feet  that  results  from 
multiple  neuritis  ;  the  spastic,  rigid,  and  trembling  legs  of  paraplegia  ; 
the  dangle-leg  of  anterior  poliomyelitis,  and  the  cerebellar  stagger  tell 
their  own  story.  Minor  peculiarities  are  no  less,  but  rather  more, 
important.  The  spinal  rigidity  and  constant  guarding  against  jars  that 
dominate  the  attitudes  and  gait  of  the  subjects  of  spinal  injuries  ;  the 
distorted  features  of  cranial-nerve  palsies,  athetoid  movements,  choreic 
twitchings,  restlessness,  slight  limps,  awkwardness,  attitudes  of  limbs, 
trunk,  or  head  long  or  customarily  maintained,  have  one  and  all  a 
significance  that  can  not  be  overestimated. 

Reduced  Motility. — For  testing  musctilar  strenr/th  numerous  re- 
cording instruments  are  available.  In  the  hand-dynamometer  of 
Mathieu  we  have  a  simple  means  of  testing  the  grasp,  and  by  fitting  it 
with  light  handles  attached  at  either  end  it  can  be  employed  in  various 
ways  to  test  the  muscular  groups  of  the  upper  and  lower  extremities. 
The  examiner  always  has  in  his  own  person  a  check  upon  the  records  of 
the   patient.     AYhen  one  handle  is  attached  to  a  hook  in  the  floor,  the 


28  NERVOUS  AND  MENTAL  DISEASES. 

lifting  jDower  of  the  back,  the  legs,  or  the  arms  is  readily  ascertained. 
Readings  on  such  an  instrument  are  of  the  greatest  value  for  clinical 
records  and  as  a  means  of  comparison  at  future  times. 

But  without  any  such  instrument  the  physician  can  roughly  test  every 
group  of  muscles  by  opposing  the  eiforts  of  the  patient.  To  examine 
flexor  and  extensor  muscles  of  the  wrist,  elbow,  and  shoulder,  instruct  the 
patient  to  resist  your  efforts  to  communicate  motion  to  the  respective 
joints.  The  same  can  be  done  in  the  lower  extremity  with  the  ankle 
and  the  knee.  The  hip  is  tested  by  having  the  patient  mount  a  chair, 
ascend  stairs,  and  raise  the  limb  to  a  horizontal  position.  Both  hands 
of  the  examiner  grasped  by  those  of  the  patient  as  vigorously  as  possi- 
ble enables  the  physician  to  compare  their  strength. 

In  hysterics  and  malingerers  it  is  sometimes  difficult  to  feel  that  full 
efforts  have  been  put  forth,  and  in  other  instances  muscular  exertion  is 
inhibited  by  pain  or  tenderness.  In  these  cases  particularly,  the 
muscular  tests  may  be  advantageously  varied  and  repeated  by  securing 
a  large  number  of  movements,  such  as  having  the  patient  stand  on  one 
foot,  rise  on  the  toes,  stoop,  crouch,  lift  chairs,  and  execute  other  tasks 
when  he  is  not  conscious  of  the  purpose  in  view.  Small  movements  of 
the  fingers  are  very  clearly  studied  as  the  patient  buttons  his  clothing  or 
handles  different  objects,  Avhich  may,  with  design,  be  placed  in  his  way. 

Where  the  degree  of  feebleness  is  slight,  it  perhaps  is  manifest 
simply  as  fatigue  after  exertion  or  in  walking  a  comparatively  short 
distance.  In  some  cases  muscles  which  at  first  register  considerable 
strength  are  rapidly  exhausted  by  a  few  full  contractions.  In  others 
initial  efforts  are  weak,  but  quickly  increase  to  a  normal  power,  making 
it  needful  to  always  take  an  average  of  several  tests. 

The  limits  of  the  paralysis  or  paresis  must  be  precisely  noted,  whether 
confined  to  a  single  muscle  or  muscle  group,  to  the  distribution  of  a 
single  nerve  or  group  of  nerves,  to  a  single  limb,  to  the  face,  to  one  side 
of  the  body  or  to  more.  If  the  involvement  is  wide-spread,  it  will  prob- 
ably vary  in  degree  in  different  regions,  and  this  is  also  of  importance. 
The  terms  monoplegia,  hemiplegia,  paraplegia,  and  diplegia  are  emj^loyed 
respectively  as  the  face  or  a  single  extremity,  the  lateral  body-half,  both 
lower  extremities,  or  both  sides  of  the  body  are  involved. 

Not  only  is  it  necessary  to  record  the  strength  of  the  muscles  under 
examination,  but  also  the  manner  in  which  they  perform.  For  all  pre- 
cise movements,  complete  balance  of  muscular  action — synergy — is  a 
prerequisite.  If  the  flexors  of  a  joint  are  weakened,  the  extensors  not 
only  fail  to  execute  their  function  with  exactness,  but  their  strength  is 
also  diminished  and  the  resulting  volitional  movement  is  weak  or  clumsy 
in  consequence.  In  conditions  marked  by  errors  of  sensation,  especially 
by  impairment  of  the  muscular  sense  which  gives  a  knowledge  of  the 
position  of  our  members  and  enables  us  to  estimate  w^eight,  movements 
become  uncertain.  This  uncertainty  is  generally  exaggerated  if  the 
movements  are  not  guided  by  the  eye.  Incoordination  of  movement 
results.  This  is  sought  for,  and,  if  present,  is  demonstrated  by  having 
the  patient,  with  closed  eyes,  touch  given  points,  either  on  his  own  person 
or  elseAvhere,    as  by  bringing  the    index  tips  of  both  hands  together, 


THE  MUSCULAR  SYSTEM.  29 

touching  the  tip  of  his  nose,  the  lobe  of  his  ear,  or  the  finger  of  the 
examiner.  In  the  lower  extremity  we  ask  liim  to  touch  a  given  object 
with  the  point  of  the  foot  or  reproduce  with  the  other  the  position  given 
a  limb  by  the  examiner.  In  making  this  last  test  it  is  necessary  to 
avoid  furnishing  the  patient  such  information  as  might  come  from  con- 
tact with  the  bed  or  personal  clothing.  Standing  with  the  eyes  closed 
and  the  feet  together,  reducing  the  base  of  support,  is  often  attended,  in 
spinal  and  other  nervous  diseases,  with  swaying  of  the  body  and  a  ten- 
dency to  fall.  This  constitutes  static  ataxia,  and  is  known  as  the  Romberg 
symptom.  It  may  be  graphically  recorded  by  attaching  a  marking-point 
to  the  patient's  head,  which  traces  his  ataxic  movements  on  a  prepared 
surface  held  at  the  proper  level.  Having  the  patient  walk  backward 
with  closed  eyes  or  stand  on  one  foot  increases  the  ataxia. 

Incoordination  may  be  very  great,  so  .that  the  blindfolded  patient 
does  not  come  within  several  inches  of  his  nose  in  his  attempts  to  touch 
it  with  his  finger,  and  has  no  certain  knowledge  of  the  position  of  his 
limbs  under  the  bed-covering  except  as  he  informs  himself  by  sight. 
While  standing,  he  may  fall  at  once  if  his  eyes  are  closed,  or  even  reel 
in  his  chair. 

The  following  example  of  ataxic  writing  shows  incoordination  very 
clearly,  and  indicates  another  important  test  of  muscular  balance  : 


I 


OAa^ 


Fig.  2. — A  specimen  of  ataxic  handwriting. 


Increased  Motility. — Perhaps  motility  in  nervous  disorders  is  more 
frequently  excessive  than  deficient — that  is,  beyond  the  purposes  of  the 
patient.  Paretic  conditions,  too,  are  not  infrequently  associated  with 
irregular  and  involuntary  muscular  movements. 

Tremors  are  the  accompaniment  of  overexertion  and  emotion  in 
health,  but  often  become  significant  symptoms  of  nervous  disturbance 
and  disease.  A  tremor  that  exceeds  six  to  the  second  is  called  rapid, 
one  below  that  rate  slow  or  moderate,  while  the  amplitude  of  the  muscu- 
lar vibration  or  excursion  is  indicated  by  the  adjectives  fine  and  coarse. 
Tremors  occur  sometimes  during  complete  rest,  as  in  paralysis  agitans, 
or  only  when  the  involved  muscles  are  called  upon  to  act — the  "  voli- 
tional or  "intention'^  tremor,  as  in  multiple  sclerosis.  While  tremors 
may  involve  the  entire  muscular  system,  as  is  often  the  case  in  exophthal- 
mic goiter,  they  may  be  restricted  to  a  single  limb  or  group  of  muscles, 
to  a  single  muscle,  or  even  to  a  few  muscle  fibrils.  This  last  constitutes 
a  fibrillary  tremor,  or,  rather,  fibrillary  spasm,  because  it  is  usually  devoid 
of  rhythm,  and  presents  only  one  or  a  few  irregular  twitchings  under 
the  integument.  They  may  sometimes  be  provoked  by  stroking  or  tap- 
ping the  surface  or  putting  the  muscle  into  operation. 


30  NEEVOUS  AND  3IENTAL  DISEASES. 

Eshner/  as  a  result  of  an  extended  series  of  experiments,  con- 
cludes :  (1)  All  muscular  movements  are  niade  up  of  a  series  of 
elementary  contractions  and  relaxations,  which  may  be  appreciable  as 
tremors  in  conditions  of  both  health  and  disease.  (2)  The  differences 
between  different  tremors  are  of  degree  rather  than  of  kind — i.  e.,  no 
form  of  tremor  is  distinctive  of  any  one  disease  or  group  of  diseases. 
(3)  No  definite  relation  exists  between  one  form  of  tremor  and  any 
other.  (4)  The  frequency  of  movement  is  in  inverse  ratio  to  the 
amplitude  and  vice  versa.  (5)  Habitual  movements  are  performed 
with  greater  freedom  from  tremor  than  unusual  movements.  (6)  There 
is  no  material  difference  between  the  movements  of  the  two  sides  of  the 
body,  except  as  related  to  proposition  5. 

In  testing  for  tremor  the  patient  is  directed  to  stretch  out  the  arms 
with  the  fingers  extended  and  separated  as  widely  as  possible.  The 
difficulty  becomes  at  once  apparent,  or  is  felt  as  a  thrill  by  the  exam- 
iner's hand  grasping  the  wrist  or  placed  against  the  finger-tips  of  the 
patient.  Care  must  be  exercised  not  to  mistake  the  origin  of  the  tremor, 
as  vibrations  of  the  head  and  extremities  may  be  communicated  from  a 
distant  point.  Again,  tremor  in  the  tongue  and  face  is  best  shown  when 
the  patient,  Avith  closed  eyes,  protrudes  the  tongue  vigorously  for  a  few 
moments.  Intention  tremors  are  usually  best  shown  when  the  patient 
attempts  to  carry  a  full  glass  of  water  to  the  lips,  to  write  with  a  pen, 
or  to  execute  other  delicate  coordinate  movements.  By  means  of 
registering  apparatus  a  tracing  of  the  tremor  may  be  obtained  in  a 
graphic  manner,  and  for  this  purj^ose  the  sphygmograph  may  sometimes 
be  employed.  The  following  specimen  of  writing  in  a  case  of  paralysis 
agitans  most  clearly  shows  the  amplitude,  rhythm,  and,  by  timing  the 
effort,  the  rate  of  the  tremor  : 

Fig.  S.^Specimen  of  handwriting  showing  tremor  of  paralysis  agitans. 

Spasms. — ^AYhen  a  muscle  or  group  of  muscles  contracts  more  or  less 
energetically  without  the  conscious  intention  of  the  individual,  it  consti- 
tutes a  sjxism,  and  is  ckmie  or  tonic  as  it  is  frequently  repeated  or 
steadily  continuous.  A  painful  spasm  is  usually  called  a  cramp,  though 
a  facial  spasm,  accompanied  with  pain,  receives  the  now  classical  desig- 
nation of  tic  douloureux. 

Long-continued  spasm  leads  to  contracture,  a  condition  in  which  the 
muscle  eventually  becomes  structurally  shortened.  Contractures  follow, 
also,  through  natural  tonus,  when  a  muscle  is  for  a  long  time  unopposed 
by  its  physiological  antagonist.  Postplegic  movements  sometimes  follow 
Vn'ain-lesious  of  long  standing.  The  paralytic  portions  of  the  body 
manifest  peculiar  involuntary  movements,  w^hich  may  vary  from  slight 
twitchings  of  a  choreic  character  to  the  never-ceasing,  purposeless  activity 
shown  in  athetosis,  where  the  fingers  and  toes  w^ork  in  a  tentacle-like,  or 
ameboid,  manner.  Voluntary  efforts  usually  increase  these  athetoid 
1  "Jour.  Exper.  Med.,"  1897. 


THE  MUSCULAR  SYSTEM.  31 

movements.  In  hemiplegia,  at  times  the  paralyzed  members  duplicate 
the  voluntary  motions  of  the  sound  side,  producing  associated  movements. 
They  are  particularly  likely  to  occur  under  instinctive  action,  such  as 
stretching  and  yawning,  or  under  strong  voluntary  efforts  with  the  sound 
side,  as  in  the  attempt  of  a  right-handed,  right-sided  paralytic  to  write 
with  the  left  hand. 

Convulsions  consist  of  more  or  less  widely-distributed,  persisting  or 
repeated  spasms,  associated  usually  with  disturbed  or  abolished  con- 
sciousness. They  are  symptomatic  of  numerous  cerebral  disorders, 
injuries,  and  intoxications.  We  speak  of  them  as  being  general  when 
the  entire  body  is  affected,  or  local  when  the  convulsive  movements  are 
confined  to  a  limited  portion  of  the  muscular  system,  as  the  face,  hand, 
or  lower  extremity.  Local  convulsions  are  frequently  styled  Jacksonian, 
especially  if  marked  by  progressive  extension  to  adjacent  muscles,  with 
tardy,  slight,  or  no  involvement  of  consciousness.  The  initial  spasm 
of  such  fits  is  called  the  signal  symptom,  indicating  fairly  the  cerebral 
center  in  which  the  muscular  storm  arises.  Convulsions  are  tonic  or 
clonic,  as  the  spasms  of  which  they  are  made  up  are  long  maintained  or 
frequently  repeated. 

The  careful  investigation  of  a  fit,  and  the  importance  attaching  to  its 
details,  their  order  of  appearance  with  all  associated  precursory  and 
sequential  phenomena,  have  already  been  touched  upon.  AVhen  these 
clinical  facts  must  be  learned  from  lay  persons  even  of  the  most  intel- 
ligent character,  the  difficulties  are  often  insurmountable.  In  some 
cases  a  trained  medical  man  or  a  well-instructed  nurse  must  remain  with 
the  patient  for  the  purpose  of  getting  a  complete  description  of  the 
attack. 

In  rare  cases  the  ordinary  muscular  tone  is  abnormally  increased, 
— myotonia.  This  gives  rise  to  a  condition  analogous  to  a  tonic  spasm, 
and  voluntary  effort  is  thereby  delayed,  as  in  Thomsen's  disease. 

Reflexes. — In  the  muscular  reflexes  we  have  a  series  of  signs  which 
give  information  regarding  both  the  spinal  centers,  and  the  nerve-paths 
above  and  below  these  centers.  They  have  great  diagnostic  value  and 
localizing  importance.  A  knowledge  of  the  spinal-cord  segments  to 
which  they  belong,  and  of  the  anatomical  relation  of  these  segments  to 
the  vertebral  bodies  and  spinous  processes,  with  the  association  of  muscle 
and  sensory  areas,  forms  the  basis  of  spinal  localization. 

A  muscular  reflex  action  is  the  result  of  a  peripheral  stimulation 
reaching  motor  spinal  centers  and  thence  centrifugally  manifest  in  a 
contraction.  Thus,  in  the  pupil,  the  stimulation  caused  by  light  falling 
on  the  retina  travels  by  the  sensory  limb  of  the  reflex  arc  to  the  medul- 
lary center,  and  there  calls  forth  energy  which  flows  down  the  motor 
limb  and  causes  pupillary  contraction.  A  blow  on  the  patellar  tendon 
stimulates  centripetally  the  lumbar  center,  and  a  contraction  in  the 
extensor  muscles  of  the  leg  results  in  the  "knee-jerk."  The  normal 
activity  of  the  reflexes  requires  not  only  the  integrity  of  the  center  and 
both  limbs  of  the  reflex  arc,  but  a  proper  association  of  the  center  with 
the  higher-lying  cerebral  levels.  Any  block  or  interruption  in  either 
limb  of  the  arc,  or  the  destruction  of  the  spinal  center,  abolishes  the 


32 


NERVOUS  AND  JIESTAL  DISEASES. 


reflex.  At  the  same  time  it  is  a  general  rule  that  pathological  conditions 
interfering  with  the  free  communication  between  spinal  center  and  cere- 
bral cortex  tend  to  increase  the  reflex  manifestations  of  the  cord.  In 
man,  however,  the  absolute  destruction  of  all  such  communication — in 
other  words,  complete  division  of  the  cord — produces  abolition  of  muscle 
reflexes  below  the  level  of  the  lesion.  Sensitiveness  in  the  part  tested  is 
ordinarily  attended  by  an  increase  of  reflex  irritability,  as,  for  instance, 
in  rheumatism. 

Reflexes  have  been  variously  described  as  skin,  superficial,  deep,  ten- 
don, muscular,  and  organic, — distinctions  that  have  no  real  value,  as 
there  is  no  essential  physiological  or  anatomical  difference.  Many  of 
them  can  be  inhibited  voluntarily  by  the  patient,  and  all  require  complete 
passivity  on  his  part  for  their  proper  investigation.  Some  only  appear 
as  a  result  of  disease.  As  a  rule,  the  muscle  under  examination  must  be 
slightly  stretched,  and  then  the  blow  or  passive  motion,  which  suddenly 
increases  its  tension,  gives  rise  to  the  reflex  movement. 

The  contact  or  threatened 
contact  of  any  object  with  the 
eyelids  or  conjunetivje  causes 
a  jmlpebral  rejlex — the  closing 
of  the  eye. 

Th^  pupillary  reflex  is  mani- 
fest under  several  conditions : 
(Ij  If  the  eyes  have  been 
closed  for  a  few  moments  and 
then  suddenly  opened  in  a 
strong  light,  or  if  in  a  dark 
room  a  beam  of  light  is  thrown 
upon  them,  the  dilated  pupils 
quickly  contract.  (2)  The 
normal  eye  shows  a  decided 
pupillar}'  contraction  if  foctised  on  a  near  object — say,  at  eight 
inches — after  being  directed  at  a  distance  of  over  twenty  feet.  This 
latter  is  sometimes  called  the  ciliary  reflex.  These  normal  reactions  are 
variously  modified  by  disease.  They  may  be  simply  sluggish,  they  may 
be  entirely  absent,  or  they  may  be  dissociated.  In  locomotor  ataxia 
and  in  paretic  dementia,  Avhen  the  posterior  portions  of  the  cervical  cord 
are  sclerosed,  the  pupils  tisually  are  narrowly  contracted.  They  then 
respond  to  efforts  of  visual  accommodation  only,  and  are  quite  insensi- 
tive to  light.  This  is  known  as  the  Argyll- Robertson  pmpil.  Rarely 
the  oppo.site  condition  has  been  noted  in  other  diseases.  The  action  of 
certain  drugs  on  the  pupil,  as  opium  and  belladonna,  is  always  to  be  kept 
in  mind  Avhen  looking  for  this  reflex,  and  the  eyes  mtist  be  separately 
observ'cd,  as  only  one  may  be  affected.  The  patient  must  not  be  allowed 
to  close  the  eyes  vigorously  in  testing  for  the  pupillary  reflex  to  light,  as 
this  act  causes  the  pupils  to  dilate,  though  covered  by  the  lids.  In  cer- 
tain conditions,  when  a  portion,  usually  one-half,  of  the  retina  is  blind  or 
insensitive,  a  narrow  ray  of  light  made  to  fall  upon  this  part  of  the  optic 
ner\'e,  by  being  thrown  obliquely  through  the  pupil,  causes  mydriatic 


Fig.  4. — Method  of  eliciting  the  jaw-jerk. 


777^  MUSCULAR  SYSTEM. 


33 


contraction.  Wernicke  first  pointed  out  tliat  this  occurred  only  when  the 
lesion  causing  hemianopsia  was  situated  back  of  the  geniculate  bodies  in 
the  optic  radiation  or  in  the  visual  centers,  and  the  condition  is  known  as 
Weniiche'H  sign.  (3)  Sharp  pinching  of  the  skin  on  the  side  of  the 
neck  and  severe  pain  in  general  cause  a  dilatation  of  the  pupil. 

The  jaw-jerk,  or  mandibular  reflex,  is  produced  best  by  placing  a 
ruler  or  similar  object  on  the  lower  incisor  teeth  while  the  mouth  is 
partially  opened,  and  striking  down  upon  it  with  a  percussion  hammer. 
This  is  followed  by  a  quick  contraction  of  masseter  and  temporal 
muscles,  and  usually  by  the  active  closing  of  both  eyes. 

The  pharyngeal  reflex  is  the  spasmodic  action,  familiar  to  every  one, 
produced  by  tickling  or  stroking  with  any  object  the  faucial  pillars  or 
the  walls  of  the  pharynx,  and  sometimes  even  the  soft  palate  or  base  of 
the  tongue.  It  is  commonly  absent  in  hysteria.  Patients  who  have 
been  subjected  to  much  local  pharyngeal  treatment  sometimes  acquire 
much  tolerance  of  manipulation  and  control  this  reflex  completely. 

In  the  upper  extremities  there  are  a  large  number  of  muscle  reflexes 
which  may  be  elicited  by  striking  on  the  insertion  tendon  after  so 
placing  the  member  that  the  muscle  under  investigation  is  put  in 
moderate  passive  tension.  Unless  the  patient  completely  relaxes,  it 
may  be  quite  impossible  to  demonstrate  the  reflex,  and  it  is  often  difficult 


Fig.  5. — Method  of  eliciting  the  elbow-jerk. 


to  secure  this  relaxation  even  in  well-intentioned  persons,  unless  their 
attention  is  distracted. 

The  various  portions  of  the  deltoids,  pedoralis  major,  trapezius, 
serratus  magnus,  and  scapular  muscles  may  be  made  to  react  in  this  way 
under  the  percussion  hammer  in  most  persons,  but  are  much  more  active 
in  neurotics  and  in  those  spinal  diseases  marked  by  increased  reflexes. 
With  the  arm  extended  and  supinated,  a  tap  at  the  insertion  of  the 
3 


34  NERVOUS  AND  3IENTAL  DISEASES. 

biceps  causes  a  flexion  movement  at  the  elbow.      The  flexors  of  the  icrist 
and  fingers  similarly  respond  while  the  extremity  is  in  this  position. 

AYith  the  elbow  flexed,  as  bv  allowing  the  arm  to  hang  over  the  back 
of  a  chair,  the  triceps  is  actuated  bv  a  tap  above  the  point  of  the  elbow. 
With  the  forearm  slightly  pronated  and  the  hand  hanging,  as  in  the 
usual  position  on  a  chair-arm,  the  larist  and  finger  exteruors  can  be 
similarly  examined.  Of  the  small  muscles  of  the  hand,  only  the 
pjahnaris  hrevis  can  readily  be  brought  into  play  in  health.  This  is 
done  by  making  pressure  over  the  pisiform  bone  and  lower  end  of  the 
ulna  with  the  thumb  and  forefinger,  and  causes  a  grooving  in  the  ulnar 
border  of  the  hand  just  above  this  point. 

In  some  spastic  cases  the  passive  sharp  flexing  of  fingers  and  wrist 
may  develop  a  v:rist  clonus,  consisting  of  rapidly  repeated  movements 
of  extension  and  flexion  at  the  joint,  which  tend  to  persist  as  long  as 
gentle  tension  is  maintained  by  the  examiner  upon  the  extensors. 

On  the  dorsum  of  the  trunk  there  are  a  series  of  reflexes  which,  below 
the  scapulae,  are  not  of  much  diagnostic  value,  and  which  can  usually  be 
demonstrated  by  stroking,  pinching,  or,  preferably,  percussing  the  mus- 
cular masses.  Anteriorly,  with  the 
patient  lying  supine  and  the  abdominal 
wall  relaxed,  a  tap  on  the  costal  cartil- 
ages on  either  side  of  the  xiphoid  de- 
pression causes  a  dimpling  or  lateral 
movement  at  this  point,  called  the 
epigastric  reflex.  A  similar  tap  on  the 
costal  border  in  the  nipple  line,  acting 
through  the  abdominal  oblique  mus- 
cle, produces  the  abdominal  reflex,  most 
noticeable  at  the  umbilicus,  which  is 
promptly  drawn  toward  the  side  per- 
^^^^  cussed  and  in  the  oblique  direction  in- 

H^^^  dicated. 

^  ^       -  ML  In  the  lower  extremities  we  find  that 

a  series  of  taps  along  the  origin  of 
the  great  gluteal  muscle,  when  the 
patient  is  erect  or  prone,  are  fol- 
lowed by  contractions  in  correspond- 
ing segments  of  that  muscle,  and  a  tap 
near  the  anterior  superior  spinous  pro- 
cess starts  the  tensor  facice  latce  femoris. 
The  knee-jerk,  or  patellar  reflex,  being 
easily  examined  and  frequently  modi- 
fied by  disease,  is  one  of  the  most  im- 
portant of  the  muscle  reflexes.  It  is 
elicited  generally  by  having  the  patient 

Fig.  6.— Method  of  eliciting  the  knee-jerk         CrOSS     OUe    kuec    OVCr    the     OtllCr     while 
and  reinforcing  it  by  Jendrassik's  method.  ■,,•  ^^K^  -i  t      i  •  ,^  ^ 

Sitting.      I  he    under    limb,    with     the 

knee  at  a  right  angle,  should  support 

the    upper,  which  gently  rests  over  it  with  all   muscles  relaxed.     A 

smart,   quick  blow  with  an   object  of  some    ounces'  weight,   as    with 


THE  3IUSCULAR  SYSTEM. 


35 


the  back  of  a  thin  book  or  the  ulnar  border  of  the  hand,  upon  the 
patellar  ligament  or  just  above  the  patella,  is  followed  by  a  con- 
traction of  the  anterior  thigh-muscles,  causing  the  suspended  foot 
to  move  forward  an  inch  or  two.  If  the  ])atient  is  in  bed,  the 
limb  to  be  examined  may  be  lightly  placed  over  its  extended  fellow, 
crossing  it  at  the  knee,  and  then  the  blow  employed,  or  with  the 
patient  on  his  side,  the  knees  partly  flexed,  the  same  thing  may  be  done. 
When  difficulty  is  encountered  in  securing  this  response,  it  is  to  be 
remembered  that  unless  the  muscles  are  fully  relaxed  the  patient  may 
inhibit  the  phenomenon,  or  that  it  may  be  so  slight  as  to  escape  attention. 
If  the  patient  be  placed  on  a  high  chair  or  on  the  edge  of  a  table  so  that  the 
legs  are  pendent,  and  at  the  same  time  his  attention  be  diverted,  the  jerk 
may  usually  at  once  be  shown.  It  can  also  be  reinforced,  as  described  hj 
Jendrassik,  by  having  the  patient  grasp  some  object  vigorously  with  his 
hands,  or  by  merely  clenching  his  hands  at  the  time  the  tendon  is  struck. 
It  should  only  be  considered  abolished  when,  thus  reinforced,  with  the 
limbs  unclothed,  the  eyes  closed,  and  the  unemployed  hand  of  the  ex- 
aminer upon  the  rectus  femoris,  no  response  can  be  detected.     Similar 


f» 


Fig.  7. — Method  of  eliciting  ankle-clonus. 


plans  of  reinforcement  are  of  value  in  testing  other  reflexes,  and  serve 
to  divert  the  patient's  attention. 

In  some  cases,  where  the  reflex  activity  is  pronounced,  by  pushing 
the  patella  sharply  downward  when  the  limb  is  extended  a  rectus  reflex 
is  produced.  If,  upon  continued  downward  pressure,  a  number  of 
rhythmic  contractions  ensue  and  are  disposed  to  continue,  we  have  the 


36  NERVOUS  AND  MENTAL  DISEASES. 

rectus  clonus.  Taps  over  the  insertions  of  the  adductor  group  and  over 
the  tendons  of  the  knee  flexors,  in  cases  marked  by  increased  reflexes, 
produce  corresponding  muscular  contractions. 

In  conditions  of  reflex  or  myotaiic  irritability,  if  the  knee  be  extended 
and  the  foot  strongly  flexed  dorsally,  a  sharp  tap  on  the  upper  and  outer 
portion  of  the  leg,  over  the  extensors  of  the  foot,  causes  a  contraction  of 
the  calf-muscles,  and  this  response  is  called  the  front-tap  contraction. 
With  the  foot  in  the  same  position,  a  tap  upon  i\\Q  Achilles  tendon  causes 
an  extension  of  the  ankle-joint.  If  there  is  doubt  about  the  presence 
of  the  heel-tendon  reflex,  place  the  patient  on  a  chair  in  the  kneeling 
posture,  direct  him  to  grasp  the  chair-back  firmly,  make  slight  pres- 
sure over  the  ball  of  the  foot  to  extend  the  tendon  and  use  the  percus- 
sor.  The  early  absence  of  this  reflex  in  sciatica  and  locomotor  ataxia 
renders  its  examination  important.  The  peroneal  muscles  likewise  re- 
spond when  properly  percussed,  the  foot  being  first  turned  somewhat 
inward  to  put  them  on  the  stretch. 

Ankle-clonus  or  foot-clonus  is  tested  by  sharply  flexing  the  foot  dorsally 
with  the  knee  extended,  and  consists  in  rhythmic  movements  of  the  foot 
upon  the  leg,  caused  by  repeated  contractions  of  the  calf-muscles.  They 
persist  usually  as  long  as  pressure  is  maintained  against  the  ball  of  the 
foot.  Sometimes  it  can  best  be  developed  by  having  the  patient,  as  he 
sits,  place  the  foot  beside  the  chair  in  such  a  way  that  the  weight  of  the 
limb  is  supported  by  the  point  of  the  foot.  The  clonus  movement  then 
causes  the  extremity  to  dance. 

A  paradoxical  persistent  contraction  is  occasionally  found  when  the 
ends  of  a  muscle  are  suddenly  and  passively  approximated.  For 
instance,  when  the  foot  is  passively  flexed  on  the  leg,  a  tonic  contraction 
of  the  anterior  tibial  muscles  takes  place.  All  other  muscle  reflexes 
are  momentary,  and  occur  under  conditions  of  extension. 

Tickling  or  stroking  the  plantar  surface  gives  rise  usually  to  well- 
known  contractions  of  a  wide-spread  character,  known  as  the  plantar 
reflex.  They  may  be  confined  to  the  flexors  of  the  toes.  Instead  of 
flexion  the  toes  may  sharply  extend,  particularly  the  great  toe,  consti- 
tuting the  important  toe-sign  of  JBabinsJci,  found  only  in  disordered, 
usually  degenerative,  conditions  of  the  pyramidal  tracts. 

When  the  skin  on  the  inner  side  of  the  thigh,  or  when  the  scrotum 
is  sharply  stroked  or  pinched,  the  corresponding  testicle  is  more  or  less 
actively  drawn  toward  the  pubic  arch  by  the  cremaster  muscle.  This 
cremasteric  reflex  must  not  be  confounded  with  the  slow  contraction  of 
the  dartos  tunic  of  the  scrotum,  of  which  it  is  entirely  independent. 

The  sphincters  of  the  bladder  and  bowel  act  reflexly  upon  the  contact 
of  any  foreign  body,  and  the  destruction  or  serious  impairment  of  these 
sphincter  reflexes  is  attended  by  incontinence.  The  sphincter  reflex  of  the 
bladder  is  tested  by  the  introduction  of  a  sound,  noting  the  presence  or 
absence  of  the  sphincteric  grasp.  A  finger  inserted  in  the  rectum  dis- 
tinctly feels  the  anal  sphincteric  reflex,  if  present.  Pinching  or  prick- 
ing the  skin  about  the  anus  causes  an  anal  reflex  consisting  in  a  pucker- 
ing of  the  mucocutaneous  margin  of  the  bowel  outlet,  and  this  may 
also  be  attended  by  a  distinct  sphincteric  contraction. 


TROPHIC  CONDITIONS.  37 

In  general,  we  may  say:  First,  that  the  Argyll-Robertson  phenome- 
non, Wernicke's  sign,  iridoplegia,  ankle-,  wrist-,  jaw-,  rectus-clonus,  and 
Babinski's  sign  are  never  found  in  health,  and  are  valuable  objective 
signs  of  central  disease.  Second,  that  the  aljolition  of  the  knee-jerk 
never  occurs  in  healthy  persons,  and  that  the  abolition  of  the  sphincter 
reflexes  is  strongly  indicative  of  central  disease.  Third,  that  the  aboli- 
tion of  the  pharyngeal  and  plantar  reflexes,  with  increase  of  others,  is 
presumptive  of  hysteria.  Fourth,  that  a  moderate  intensification  of  all 
reflexes  indicates  neurasthenia.  Fifdi,  that  the  abolition  of  all  reflexes 
in  a  given  anatomical  area  points  to  histological  disease,  either  central 
or  peripheral,  in  the  arcs  supplying  those  reflexes. 

It  should  be  pointed  out  that  in  hysteria  and  neurasthenia  there  is 
sometimes  a  spurious  anJdc-clonus  that  may  be  misleading,  the  foot  mak- 
ing a  few  vibrations  only  upon  the  institution  of  the  test.  In  this  con- 
dition, too,  there  is  a  tendency  for  the  reflexes  to  be  wide-spread,  so  that 
a  tap  upon  one  patellar  tendon  may  cause  both  legs  to  respond,  start  the 
upper  extremities,  or  almost  convulse  the  patient. 

Myoidema,  or  idiopathic  muscular  sjKism,  is  produced  in  certain  irri- 
table conditions  by  sharply  striking  across  the  muscle  with  a  ruler  or 
similar  instrument,  causing  a  local  contraction  at  the  point  struck,  with 
a  bunching  up  of  the  muscular  tissue  that  persists  from  a  few  seconds 
to  several  minutes. 


CHAPTER  IV. 
TROPHIC  CONDITIONS. 

The  significance  of  abnormal  variations  in  the  nutritional  conditions 
of  a  part  is  at  once  apparent  when  it  is  recalled  that  the  growth  and 
nourishment  of  all  the  structures  of  the  body  are  presided  over  by 
trophic  centers  acting  through  peripheral  nerves.  For  the  proper 
nutrition  of  skin,  mtiscle,  nerve,  and  bone  the  integrity  of  the  trophic 
center,  of  its  peripheral  path,  and  of  its  termination  is  essential,  In  other 
words,  the  anterior  spinal  cell  and  its  polar  prolongation  in  the  efferent 
nerve,  the  lower  neuron,  can  not  be  injured  or  destroyed  without  corre- 
spondingly impairing  the  function  of  nutrition  in  its  area  of  distribution. 
All  diseases,  therefore,  which  affect  the  anterior  spinal  gray  matter  or  the 
peripheral  nerves  are  symptomatized  by  trophic  changes  in  the  associated 
parts.  Further,  in  some  local  conditions  of  disturbed  nutrition,  where 
even  upon  minute  examination  of  trophic  cells  and  efferent  nerves  we 
can  not  discern  any  abnormality  with  all  the  means  now  at  command, 
still  we  are  justified  by  analogy  in  supposing  some  modification  of  this 
trophic  energy,  some  dynamic  change,  some  perversion  of  the  ftinction 
of  the  trophic  apparatus  relating  especially  to  its  center. 

It  is  also  evident  that  some  substances  act  as  stimulants  to  the 
trophic  centers.  This  is  seen  in  the  hypertrophies  of  acromegalia  and 
myxedema,  w^here  there  is  a  perverted  action  of  certain  ductless  glands. 
Other  agents,  as  perhaps  lead,  may  have  a  depressing  effect  upon  these 


38  NERVOUS  AND  MENTAL  DISEASES. 

centers.  The  blood-supply  of  a  part  and  its  nutrition  are  intimately 
associated.  The  vasomotor  and  trophic  apparatus  are  apparently 
mutually  dependent,  and  as  a  matter  of  clinical  fact  it  is  constantly 
observed  not  only  that  in  wasted  tissues  the  blood-supply  is  greatly 
reduced,  but  that  in  hypertrophic  states  the  vascularity  is  increased. 

When  the  trophic  apparatus  of  a  limb  is  involved,  the  various  tissues 
suifer  in  proportion  as  they  are  highly  organized.  Fibrous  tissue, 
cuticular  epithelium,  and  bone  are  but  slightly  modified,  though  their 
growth  and  repair  may  be  stopped,  while  the  more  vascular  and  highly 
organized  muscles  and  nerves  promptly  waste. 

The  Skin. — In  conditions  of  acute  trophic  irritation,  as  in  herpes 
zoster,  the  skin  becomes  injected,  red,  and  painful,  and  the  epidermis  is 
raised  in  blebs  or  bullae  filled  with  serum.  When  the  condition  is  one 
of  chronic  trophic  irritation,  the  skin  may  become  thickened,  infiltrated, 
boggy,  and  show  an  actual  hypertrophy  of  the  subcutaneous  areolar 
structure.  The  epidermis  is  increased  in  thickness,  presenting  scales 
and  roughness,  with  an  increase  in  the  growth  of  hair  and  the  secretion 
of  sweat.  The  nails  become  rough,  striated,  coarse,  and  grow  rapidly. 
Diminished  trophic  energy  is  marked  by  opposite  conditions.  The 
epidermis  is  thinned,  imperfect,  dry,  and  non-resisting  to  ordinary  wear  ; 
the  hair  becomes  brittle,  scant,  and  sometimes  turns  gray  ;  the  nails 
grow  slowly  and  imperfectly.  The  dermal  envelope  closely  binds  the 
underlying  parts,  loses  its  pliability  and  softness,  and  presents  a  reddish, 
purplish,  or  glistening  whitish  appearance. 

The  muscles  show  disturbance  of  trophic  enervation  very  promptly. 
Acute  poliomyelitis,  or  division  of  a  peripheral  nerve,  is  followed  in  a 
few  hours  by  a  muscular  relaxation  that  is  quite  apparent,  and  in  a  few 
days  the  part  looks  wasted,  though  it  may  show  no  change  on  measure- 
ment. At  the  end  of  a  fortnight  a  lessened  size  can  be  easily  demon- 
strated. The  sarcode  elements  rapidly  alter  and  tend  to  disappear, 
finally  leaving  only  the  fibrous  constituents  to  represent  the  muscle  by 
a  band  of  dense  tissue,  which  shortens,  gradually  producing  contractures 
and  deformities. 

In  those  conditions  where  the  process  is  slower,  the  muscle  does  not 
change  en  masse,  but  is  gradually  invaded  by  the  atrophy  and  shows 
some  normal  fibers  very  late  in  the  disease  and  others  that  may  be 
actually  hypertrophied.  In  pseudohypertrophic  paralysis  the  muscles 
become  infiltrated  with  fat,  which  displaces  the  muscle  elements,  exag- 
gerates the  muscular  firmness  and  outlines,  and  gives  a  false  appearance 
of  strength. 

The  peripheral  nerves,  when  cut  off  from  their  trophic  centers  in  the 
anterior  spinal  gray  matter,  show  similar  degeneration.  Under  con- 
ditions of  trophic  irritation  they  present  proliferation  of  their  fibrous 
structures  and  general  thickening  of  their  trunks,  with  more  or  less 
disintegration  of  their  nobler  elements.  Optic-nerve  atrophy  is  a  visible 
instance  of  this  kind. 

The  lowly  organized,  almost  non-vascular  tendons  and  ligaments  in 
adult  cases  show  little  change  when  deprived  of  their  nerve-supply,  but 
even  bone  itself  becomes   less  resistant,  more   fragile,  and   somewhat 


ELECTRICAL  CONDITIONS.  39 

rarified  uutler  these  couditioiis.  In  children  bony  growth  is  usually 
seriously  checked. 

The  trophic  condition  of  joints  in  nervous  affections  is  one  of  great 
interest.  In  tabes  dorsalis,  and  more  rarely  in  other  organic  diseases  of 
the  brain  and  spinal  cord,  as  in  progressive  spinal  muscular  atrophy  and 
cerebral  palsy,  great  changes  take  place  in  various  joints.  They  become 
enlarged,  enormously  distended  with  fluid,  and  the  bones  disintegrate 
without  any  painful  attending  symptoms.  This  condition  of  dystrophie 
arthrojjaflii/  was  first  clearly  recognized  by  Charcot,  and  the  articulations 
thus  affected  are  often  called  Charcot  joints.  Again,  arthritis  of  any 
character  may  be  followed  by  extensive  atrophy  of  the  muscles  above 
the  joint,  principally  those  of  extension.  This  arthritic  muscular  atrophy 
in  which  the  muscles  waste,  but  conserve  their  electrical  and  reflex 
responses,  is  attributed  to  an  irritant  condition  which  arises  in  the 
inflamed  joint.  It  affects  the  trophic  spinal  centers,  and  thence  acts 
upon  the  nutrition  of  the  particular  muscles  physiologically  associated 
with  that  joint.  It  is  positively  known  that  division  of  the  afferent 
path  from  the  inflamed  joint  to  the  spinal  center  prevents  the  atrophic 
sequel. 

Decubitus. — In  acute  processes  involving  the  spinal  cord  an  acute 
bedsore  sometimes  appears  in  a  few  days,  completely  denuding  the 
sacrum.  While  this  may  be  favored  by  pressure  due  to  the  position  of 
the  body  and  moisture  from  the  urinary  incontinence  that  is  often 
present,  it  may  also  appear  independently.  Gross  cerebral  lesions  are 
similarly  marked  in  some  cases  by  a  sloughing  of  the  buttocks,  and  this 
•decubitus,  as  in  the  spinal  lesions,  is  doubtless  primarily  due  to  inter- 
ference with  the  trophic  control,  and  in  the  case  of  hemiplegia  affects 
the  paralyzed  side  only. 

Acute  cystitis  in  paraplegic  states,  the  low  resistance  of  the  tissues 
to  pressure  or  heat,  and  the  tardiness  of  repair  have  a  similar  significance 
and  add  greatly  to  the  difficulty  of  caring  for  such  patients. 

Symmetrical  limited  deposits  of  fat  and  pigment,  Raynaud's  disease, 
symmetrical  scleroderma,  and  scleroderma  in  the  form  of  striee  atrophicse 
following  the  nerves  are  clearly  due  to  trophic  disturbances,  and  are 
classed  among  the  trophic  neuroses. 

Local  conditions  of  trophic  impairment  may  be  a  part  of  general  ill- 
health  or  systemic  diseases,  and  may  in  some  cases  be  due  to,  but  should 
not  be  confounded  with,  them.  Disuse  will  also  produce  marked  nutri- 
tional changes  in  a  part,  as  inactivity  does  of  the  entire  organism, — 
a  fact  to  be  borne  in  mind  in  relation  to  neurasthenics,  hysterics,  and 
malingerers. 

CHAPTER  V. 
ELECTRICAL  CONDITIONS. 

Normal  muscles  and  nerves  respond  to  various  methods  of  electrical 
stimulation  in  a  precise  and  uniform  manner.  On  the  other  hand,  dis- 
eases which  modify  the  electrical  conductivity  of  nerves  or  their  muscle- 
endings  and  diseases  which  modify  the  electrical  stimulability  of  muscle- 


40 


NERVOUS  AND  MENTAL  DISEASES. 


cells  produce  characteristic  changes  in  their  reactions  when  properly 
tested.  These  changes  are  of  very  great  diagnostic  importance.  We 
require,  for  a  reasonable  examination  of  this  nature,  first,  an  induced  or 
faradic  current  that  can  be  increased  from  zero  to  a  tetanizing  strength  ; 
and,  second,  a  constant  or  galvanic  current  of  at  least  fifty  volts'  strength, 
that  can  also  be  gradually  and  uniformly  increased  or  decreased  at  will 
or  interrupted  at  pleasure.  The  first  is  supplied  in  many  convenient 
and  portable  forms,  of  which,  perhaps,  the  best  is  the  chlorid  of  silver 
dry-cell  battery,  fitted  with  an  induction  apparatus  of  the  Keymond 


M.  frontalis 

Upper  branch  of 
facial 
M.  corrug. 
supercil. 

M.  orbic.  palpebr. 
Muscles  of  the  f 


M.  zygoinatici 

M.  orbicul.  oris  < 
I 
Middle  branch  of 
facial. 

M.  luasseter 

M.  levator  menti 

M.  qiiadr.  menti 

M.  triaiig.  menti 

N.  hyjiogloss. 

Lower  branch  of 

facial 

M.  platysma 

mvoides 


Muscles  of  the 
root  of  tongue 


{I 


M.  omohvoideus 


N.  thoracic,  anter. 
(M.  jiector.j 


N.  phrenicus 


Suprascapular 
point.     (Erb's  point. 
M.    deltoid.,    biceps, 
brachial,  intern,  and 
supinat.  long.) 


Plexus 
brachialis 


Region  of  central 
convolutions 


Region  of  the 
third  frontal 
convolution 

M.  temporalis 

Upper  branch  of 
facial  in  front 
of  ear 

N.  facialis 

N.  aiiriculo.  post. 
Miildle  branch  of 

facial 
Lower  br.  of  facial 
M.  spleiiius 

M.  sternocleido- 

mastoideus 
N.  accessorius 

M.  levator  anguli 

scapulae 
M.  cucullaris 

N.  dors,  scapulce 


N.  axillaris 


N.  thoracic,  long. 
(M.  serratus 
antic,  maj.) 


Fig.  8. — Nerves  and  motor  points  in  face  and  neck. 


type  ;  the  second  by  about  thirty  active  Leclanch6  or  equivalent  cells,  or 
the  incandescent  lighting  circuit  modified  by  a  proper  rheostat.  For 
portable  purposes  batteries  of  various  makers  containing  from  twenty  to 
fifty  cells  are  available.  Two  electrodes  are  needed,  one  presenting 
from  nine  to  twelve  square  inches  of  conducting  surface,  the  other  fitted 
with  an  interrupting  handle  by  which  the  operator  can  easily  control  the 
current,  and  having  a  rounded  conducting  surface  about  one  inch  in 
diameter. 


ELECTRICAL  CONDITIONS. 


41 


When  using  the  constant  enrrent,  a  milliamperemeter  is  of  value 
and  for  purposes  of  record  ahnost  a  necessity.  Its  readings  show  the 
amount  of  current  in  circuit  at  the  particular  time.  It  is  to  be  remem- 
bered that  all  alterations  in  the  condition  of  the  test — such,  for  instance, 


M.  triceps  (caput   

longum) 


M.  triceps  (caput 
intern. 


M.  flexor  carpi  ulnaris 

M.  flex,  digitor.  com- 
mun.  profund. 


M.  flex,   digitor.  sub 
lim.  (digiti  II  et  III) 


M.  flex,  digit,  subl. 
(digit,  indicis  et 
minimi) 

Nerv.  ulnaris 


M.  palmaris  brev. 

M.  abductor  digiti 

mill. 

M.  flexor  digit,  min. 

M.  opponens  digit. 

min. 


M.  lumbricales 


M.  deltoideus 

Nerv.  musculocutaneus 
M.  biceps  braohii 
M.  brach.  internus 


Nerv.  inedianus 
M.  supinator  longus 
M.  pronator  teres 
M.  flex,  carpi  radialis 

M.  flexor  digitor.  sublim. 

M.  flex,  pollicis  longus 
Nerv.  medianus 

M.  abductor  pollic.  brev. 
M.  opponens  pollicis 

M.  flex.  poll.  brev. 

M.  adductor  pollic.  brev. 


Fig.  9.— Nerves  and  motor  points  in  upper  extremity. 

as  dryness  of  the  electrodes  or  of  the  skin  of  the  patient — modify  the 
amount  of  electricity  requisite  to  secure  a  given  response.  Probably 
identical  conditions  can  not  be  secured  even  with  the  same  patient  twice 
in  succession.  All  ampere  measurement  comparisons  are  therefore  rela- 
tive and  approximate.     Cells  vary  so  much  in  activity  at  different  times 


42 


NERVOUS  AND  MENTAL  DISEASES. 


that  to  base  the  record  upon  the  number  used  is  futile.  Where  a 
rheostat  is  employed  in  controlling  a  lighting  current  of  a  given  poten- 
tial, an  index  scale  can  be  arranged  that  will  furnish  lairly  satisfactory 
records. 

A  uniform  method  of  making  electric  tests  is  important.      The  ar- 
rangement of  electrodes  recommended  by  Erb  and  found  satisfactory  in 


M.  deltoideus 


N.  radialis 
M.  brachial,  intern. 

M.  supinator  long. 
M.  radial,  ext.  long. 
M.  radial,  ext.  brev. 


M.  extensor  digit,  communis  \ 

M.  extensor  indicis 
M.  abductor  pollic.  long. 
M.  extensor  pollic.  brev. 


M.  inteross.  dorsal, 


M.  triceps  (caput  longum) 


M.    triceps    (caput    ex- 
tern.) 


M.  ulnar,  extern. 
M.  supinat.  brev. 

M.  extens.  digiti  minim. 
M.  extens.  indicis 

\  M.  extens.  poll.  long. 


M.  abduct,  digit,  min. 

M.   inteross.  dorsal.  Ill 
etIV 


Fig.  10.— Nerves  and  motor  points  in  upper  extremity. 


all  instances  is  perhaps  the  best.  The  large  or  indifferent  electrode 
thoroughly  moistened  in  warm  water,  with  which  it  is  also  well  to  wet 
the  skin,  is  applied  over  the  sternum,  where  the  absence  of  muscles  and 
of  much  sensitiveness  obviates  disturbing  features.  The  small  or  active 
electrode,  fitted  with  an  interrupter  and  well  moistened,  is  then  placed 
over  the  nerve  or  muscles  to  be  examined,  and  the  current  allowed  to 
pass  (that  is   ''made'')  or  is  interrupted  (that  is,  "broken")  as  required. 


ELECTEICAL  CONDITIONS. 


43 


This  interference,  for  the  sake  of  brevity,  is  called  the  make  and  break 
of  the  constant  current. 

In  Health. — The  nerve-trunk — as,  fur  instance,  the  ulnar  at  the 
elbow — in  a  healthy  person,  when  stimulated  by  a  mild /cwarfic  current, 
causes  all  the  muscles  to  which  it  is  distributed  to  contract  more  or 
less  vigorously  in  proportion  to  the  intensity  of  the  current  employed. 
It  is  to  be  particularly  noted  that  upon  allowing  the  current  to  pass 
the  response  is  instantaneous,  and  that  the  muscular  contraction  at 
once  reaches  its  maximum  and  maintains  it  until  the  current  is  modi- 
fied. This  phenomenon  attends  stimulation  by  either  the  positive  or 
negative  faradic  pole  or  electrode,  but  the  negative  causes  a  slightly 
stronsrer  elFect. 


N.  obturator 
M.  pectineus 

M.  adductor  magnus 
M.  adduct.  loiigus 


M.  cruralis 


M.  vastus  internus 


M.  tensor  faseise  latse 

M.  sartorius 

M.  quadriceps  femoris 

M.  rectus  femoris 

M.  vastus  externus 


Fig.  11. — Nerves  and  motor  points  in  lower  extremity. 


If,  now,  the  constant  current  be  substituted,  we  notice,  first  of  all,  that 
mild  currents  applied  to  the  nerve-trunk  produce  no  response.  When 
the  current  is  sufficiently  increased  it  causes,  only  at  the  make  and 
break,  single  instantaneous  contractions  of  the  innervated  muscles,  which 
as  quickly  subside.  Looking  closer,  we  notice  that  the  contraction  with 
the  negative  make — otherwise  the  cathodal  closing  contraction  (C.  C.  C.) — 
is  the  first  to  appear  as  the  current  is  gradually  increased,  that  next 
comes  the  positive  make,  or  anodal  closing  contraction  (A.  C.  C),  followed 
in  turn  by  the  positive  break,  or  anodal  opening  contraction  (A.  O.  C), 
and  then,  finally,  by  the  negative  break,  or  cathodal  opening  contrac- 
tion (C.  O.  C).  '  Further,  that  by  the  time  we  have  C.  O.  C.,  A.  O.  C. 


44 


NERVOUS  AND  MENTAL  DISEASES. 


will  be  vigorous,  A.  C.  C.  very  strong,  aud  C,  C.  C  produces  a  con- 
stant tetanic  condition  lasting  as  long  as  the  current  flows  when  once 
it  is  set  up  by  the  make, — a  condition  called  cathodal  closing  tetanus 
(C.  C.  T.). 

The  contractions  from  stimulating  the  nerve-trunk  thus  in  health 
appear  in  the  following  order  :  C.  C.  C,  A.  C.  C,  A.  O.  C,  and 
C  O.  C,  and  this  indicates  their  intensity  in  a  decreasing  order.  The 
important  point   to   constantly  bear  in  mind  is  that  the  negative  make 


Nerv.  ischiadicus 

M.  biceps  fern.  (cap.  long.) 
M.  biceps  fern.  (cap.  brev.) 


N.  peroneus 
M.  gastrocnem.  (cap.  extern.) 

M.  soleus 
M.  flexor  hallucis  longus 


jw      \  M.  gluteus  maximus 


M.  adductor  magiius 
M.  seraitendinosus 
M.  semimembranosus 


M.  gastrocnem.  (cap.  int.) 


M.  flexor  digitor.  comm.  longus 


N.  tibialis 


Fig.  12. — Nerves  and  motor  points  in  lower  extremity. 


This 


contraction  through  healthy  nerves  is  stronger  than  the  positive, 
fact  is  thus  formulated  :  C.  C.  C.>A.  C.  C. 

When  the  active  electrode  is  applied  over  the  belly  of  a  given 
muscle,  a  muscular  contraction  is  set  up  by  the  faradic  current,  the 
same  as  that  produced  by  stimulating  the  nerve-trunk.  If  the  current 
be  not  too  strong  and  the  electrode  not  too  large,  the  effect  may  be 
limited  to  the  given  muscle,  or  to  a  portion  of  a  muscle.  Every  mus- 
cle may  also  be  actuated  by  the  galvanic  current  by  applying  the  active 


ELECTRICAL  CONDITIONS. 


45 


pole  on  the  point  corresponding  anatomically  to  the  entrance  of  its 
motor  nerve.  A  familiarity  with  motoi'  points  is  of  practical  importance. 
They  are  shown  in  the  accompanying;  diagrams.  Slight  variations  in 
their  location  are  common,  and  several  trials  are  often  required  to  find 
them.  It  is  well  to  mark  with  a  lead-pencil  the  necessary  points, 
if  repeated  tests  are  to  be  employed.  The  galvanic  jiolar  responses 
are,  in  healthy  muscles,  identical  with  those  obtained  through  the  nerve- 
trunks. 

In  Disease. — Diseases  changing  the  nutrition  and  structure  of  the 
lower  neuron,  which  consists  of  the  spinal  cell-body  and  its  peripheral 
projection  and  termination  in  muscular  tissue,  alter  not  only  the  trophic 
conditions  over  which   the  neuron   presides,  but  also  interfere  with   its 


M.  tibial,  antic. 

M.  extens.  digit,  coram, 
long. 


M.  peroneus  brevis 


M.  extensor  hallucis 
long. 


Mi.  interossei  dorsale; 


Nerv.  peroneus 


M.  gastrocnem.  extern. 
M.  peroneus  longus 


M.  soleus 


M.  flexor  hallucis  long. 


M.  extens.  digit,  comm. 
brevis 


--   M.  abductor  digiti  min. 


Fig.  13. — Nerves  and  motor  points  in  lower  extremity. 


electric  properties.  If  the  spinal  cell  be  destroyed,  or  its  peripheral 
filament  divided,  degeneration  follows  below  the  lesion,  in  both  the  nerve 
arid  muscle,  with  loss  of  voluntary  control.  The  reactions  of  such  a 
nerve  and  muscle  to  electricity  are  modified  in  a  highly  characteristic 
manner.  They  present  the  reaction  of  degeneration  (K.  D,),  the  presence 
of  which  is  an  indubitable  sign  of  structural  change.  At  the  end  of 
about  a  week,  during  which  there  has  been  a  gradual  decrease  of  electric 
excitability  in  the  muscle  and  nerve  to  both  faradic  and  galvanic  shocks, 
four  differences  become  manifest : 


46 


NEEVOUS  AND  MENTAL  DISEASES. 


First.  The  muscle  responds  weakly,  sluggishly,  and  deliberately  to  fara- 
dism,  and  shows  a  tendency  to  maintain  the  contraction  after  the 
current  is  withdrawn.     This  is  the  modal  change. 

Second.  The  nerve-trunk  loses  progressively  and  equally  its  responsive- 
ness to  both  galvanism  and  faradism — a  quantitative  change. 

Third,  The  7?u(sc/e  becomes  much  more  excitable  by  galvanism  and  much 
less  excitable  by  faradism,  which  latter  reaction  with  the  nerve- 
trunk  responses  is  completely  lost  after  two  or  three  weeks.  This  is 
the  qualitative  change. 

Fourth.  A  po/«?'  chcrnge  appears  in  the  muscle  about  the  second  week 
when  directlv  stimulated  by  galvanism.  It  is  now  found  not  only 
that  the  muscle  is  more  readilv  caused  to  contract  bv  the  constant 


-^    Gail/iniC— 

3      ■•     ' 

S(  fara-dic 

^  f  Galvanic 
"^l  „  ana 


Health. 


j_  °y|ieri/e  fro hfe ration.  tfflTluSCle        t^egeReraiioTi.       jj 


eaiik 

JO      ji      'is,  WeeK 


Vo'-^  motion 


^[Gd^lvA-nic 
^[fd.rA6ic 


flealtk 


"i  Herue 


Jlfrophxj  a--ci)  Prolife  ration,  of  iTlusele,  CirrliQSis      DqSi^ 


'o^Hiair 


Fig.   14.— 1,  Paraly.sis  with  early  return  of  motion  (modified  from  Erb).     2,  Incurable  paralysis  -with 
complete  atropiiy  and  degeneration  (modified  from  Erb). 


current,  but  that  the   normal  mastering  strength  of  the  negative 
closing  contraction  over  the  positive  has  disappeared  and  that  the 
positive  closing  contraction  is  equal  to  or  greater  than  the  negative. 
Expressed  thus  :  A.  C.  C.=  or  >  C.  C.  C.    Anodal  tetanus  (A.  T.) 
is  often  obtained.     This  polar  difference  continues  until  the  nerve 
either  regenerates  and  regains  its  normal  status,  or,  failing  to  recover, 
gradually  the  galvanic  irritability  subsides.      It  is  entirely  abolished 
with  all  other  electrical  responses  in  complete  degeneration. 
Should  recovery  take  place,  the  restitution  is  marked  ordinarily,  first, 
by  a  return  of  voluntary  control,  then,  by  the  appearance  of  galvanic 
and  faradic  excitability  in  the  nerve,  and,  la.st  of  all,  by  faradic  excita- 
bility of  muscle.     The  hyperexcitability  of  the  muscle  to  galvanism  and 


ELECTRICAL  CONDITIONS.  47 

the  polar  variations  from  the  normal  gradually  right  themselves  at  the 
same  time.  These  changes  and  the  pathological  process  in  nerve  and 
muscle  are  shown  in  the  diagrams  (Fig.  14)  modified  from  Erb. 

In  some  cases  we  find  a  jjartial  reaction  of  degeneration,  the  nerve- 
trunk  response  being  only  slightly  modified.  The  inverted  polar  formula 
is  not  necessarily  present.  The  mod  essential  element  in  the  reaction 
of  degeneration  is  the  modal  change, — the  slowly  appearing  muscular 
response, — ^so  at  variance  with  the  instantaneous  effect  produced  in  health. 
Next  in  importance  is  the  lessened  faradic  control  of  the  muscle,  and,  last, 
the  polar  modifications.  The  variations  in  the  galvanic  and  faradic 
responses  in  disease  are  due  principally  to  the  fact  that  currents  of  a 
certain  strength  and  duration  are  required  to  actuate  the  changed  sarcode 
cells,  and  the  rapidly  interrupted  faradic  current  thereby  becomes 
inoperative.  The  galvanic  current,  if  interrupted  with  sufficient  rapid- 
ity, is  equally  powerless. 

In  some  conditions  is  found  a  simple  increase  or  decrease  of  electrical 
excitability,  constituting  a  pure  quantitative  change.  In  those  diseases 
where  the  muscles  seem  permanently  affected,  as  in  the  progressive 
atrophic  myopathies,  the  responses  are  reduced,  but  are  proportionate  to 
the  amount  of  healthy  muscular  fibers  remaining.  Some  spasmodic  con- 
ditions, like  facial  tic,  present  an  increased  activity  to  electric  stimulation. 
There  is  increased  electrical  excitability  in  tetany  and  in  Graves'  dis- 
ease. In  myotonia  we  encounter  a  peculiar  electrical  response  called 
the  myotonic  reaction.  In  this  condition  there  is  normal  faradic  ex- 
citability of  nerves,  but  the  electrical  excitability  of  the  muscles  is 
greatly  enhanced  to  all  forms  of  current.  The  positive  and  negative 
closing  galvanic  contractions  are  nearly  equal  and  all  responses  are  tonic 
and  prolonged.  The  mechanical  excitability  of  the  muscles,  as  to 
blows,  is  similarly  exaggerated.  In  myasthenia  gravis  the  muscular 
responses  are  rapidly  exhausted  by  repeated  stimulation  with  faradism 
or  galvanism.  They  gradually  lose  force  as  the  stimulus  is  repeated, 
and  in  a  few  moments  fail  completely,  but  reappear  after  a  short  rest. 
This  peculiarity  is  called  the  myasthenic  reaction. 

The  use  of  electricity  to  test  cutaneous  sensation  is  open  to  so  many 
errors  and  attended  by  so  much  difficulty  that  simpler  means,  always  at 
hand,  are  to  be  preferred.  In  those  feigning  complete  cutaneous  anes- 
thesia the  surprise  of  a  strong,  painful,  faradic  current  from  a  dry,  metal 
electrode  will  be  likely  to  unmask  the  deceit. 

When  the  active  electrode  is  placed  over  the  closed  eye  or  at  the 
temple,  the  make  or  break  of  constant  currents  is  attended  by  a  subjective 
sensation  of  light,  and  this  test  serves  to  show  the  activity  of  the  retina 
and  optic  nerve.  By  placing  the  indifferent  electrode  on  the  same  side 
of  the  neck,  one  eye  at  a  time  may  be  examined,  and  for  this  purpose 
only  small  currents — from  two  or  three  cells  or  of  as  many  milliamperes 
— should  be  used.  In  the  same  way  either  auditory  nerve  may  be  tested 
by  placing  the  active  electrode  over  the  mastoid  or  before  the  tragus, 
the  negative  pole  producing  much  the  louder  sound. 

For  testing  the  nerves  of  taste  the  galvanic  current  is  a  prompt  and 
reliable  agent.      By  those  of  keen  perceptions  a  difference  between  the 


48  NERVOUS  AND  3IENTAL  DISEASES. 

positive  and  negative  pole  can  be  distinguished.  For  the  ordinary 
purpose  of  taste  testing,  electrodes  ending  in  probe-pointed  metal 
terminals,  or  even  the  metal  ends  of  conducting  cords  held  to  the  tongue 
or  pharynx,  at  once  give  rise  to  an  acid  or  salty  taste,  which  is  quickly 
appreciated  by  the  patient.  One  or  two  cells  are  all  that  is  required, 
and  one  side  of  the  tongue  can  be  easily  compared  with  the  other  in 
lateral  lesions,  or  the  tongue  of  a  healthy  individual  will  furnish  a 
standard  when  needed. 

For  the  purpose  of  localizing  the  various  muscular  areas  in  the  sen- 
sori-motor  zone  of  the  cerebral  cortex,  when  it  is  exposed  surgically  oi 
otherwise,  a  mild  faradic  current  is  used.  It  is  applied  to  the  brain 
surface  by  two  probe  poles,  preferably  mounted  on  a  single  handle,  and 
so  arranged  that  their  extremities  may  be  fixed  at  any  distance  apart. 
Such  a  current  thus  applied  causes,  in  the  related  muscular  periphery, 
similar  responses  to  those  produced  by  faradizing  the  nerve-trunk, 
but  the  movement  has  more  of  a  purposive  or  gesticulatory  charac- 
ter. These  responses  also  follow  an  extradural  application  of  the 
electrodes. 


SENSOEY  CONDITIONS.  49 


CHAPTER  VI. 
SENSORY  CONDITIONS. 

Modifications  of  sensation  are  among  the  commonest  conditions 
attending  nerve-lesions  and  functional  disturbance  of  the  neural  appa- 
ratus. It  is  well  to  have  a  prefatory  understanding  of  the  fact  that 
sensation,  of  whatever  variety  or  quality,  is  due  to  the  appreciation  of 
temporary  motion  and  contact,  or,  in  simpler  terms,  that  all  sensations 
are  modifications  of  touch.  It  is  the  impact  of  luminous  and  sound- 
waves on  properly  qualified  nerve  expansions  that  gives  rise  to  sensations 
of  sight  and  hearing.  The  contact  of  odorous  and  sapid  particles  stim- 
ulates the  sensations  of  smell  and  taste.  The  recognition  of  the  va- 
rious qualities  of  objects  in  contact  with  the  skin  gives  us  information  of 
size,  shape,  temperature,  hardness,  smoothness,  and  a  thousand  physical 
properties  of  the  external  world. 

Another  general  consideration  is  that  any  overstimulation  of  sensory 
nerves  is  painful.  That  which  is  so  readily  called  the  pain  sense  is  but 
the  subjective  recognition  of  this  overstimulation  coupled  by  instinct 
and  experience  with  the  concept  of  harm.  Thus  the  contact  of  a  sharp 
point  is  at  first  so  recognized  and  the  sense  of  pain  comes  when  the  pres- 
sure is  increased  and  the  stimulation  intensified.  It  can  not  be  doubted, 
however,  that  pain  and  thermic  sensations  have  courses  in  the  spinal  cord 
separate  from  tactile  impressions.  Extremes  of  heat,  cold,  pressure, 
noise,  light,  odors,  and  tastes  give  rise  to  pain  or  to  discomfort  analo- 
gous to  pain.  They  cause  automatic  or  conscious  efforts  of  avoidance 
and  self-preservation.  It  is  also  a  matter  of  common  experience  that 
sensations,  except  of  an  extremely  painful  character,  if  long  maintained, 
are  more  or  less  completely  ignored.  Therefore,  to  elicit  sensation  the 
motion  or  contact  must  be  temporary  or  repeated  after  distinct  intervals. 
Clothing  to  which  we  are  habituated  gives  rise  to  little  or  no  conscious 
sensation.  With  the  long  persistence  of  an  odor  there  is  a  gradually 
diminishing  perception  of  it.  On  the  other  hand,  the  sudden  stopping 
of  a  clock  or  other  familiar  and  disregarded  sound  is  almost  startling. 

In  considering  the  various  qualities  and  modifications  of  the  sense  of 
touch  it  is  requisite  to  bear  in  mind  that  keenness  of  sensibility"  varies 
greatly  not  only  in  different  cutaneous  areas  in  a  given  subject,  but  con- 
siderably in  different  individuals.  The  more  keen,  active,  and  intelli- 
gent the  make-up  of  the  subject,  the  quicker  and  more  precise  are  the 
responses.  To  all  tests  of  sensation  the  disadvantage  pertains  that  we 
are  dependent  upon  the  responses  of  the  person  tested  ;  so  that  such  tests 
are  only  partly  objective.  Sudden  extreme  pain,  however,  is  usually 
attended  by  certain  recognizable  signs,  such  as  change  of  countenance, 
quickened  pulse,  dilated  pupil,  pallor,  and  even  perspiration.  To  carry 
out  the  needful  tests  we  require  the  intelligent  cooperation  of  the  patient, 
and  to  this  end  he  must  understand  exactly  what  is  sought.  In  order 
4 


50  NERVOUS  AND  3IENTAL  DISEASES. 

that  his  replies  may  depend  upon  his  receiving  information  through  the 
tested  source  alone,  the  eyes  should  be  bandaged  or  other  suitable  pre- 
cautions taken  to  prevent  their  use.  Check  tests  must  also  be  used, 
such  as  asking  "  what  is  felt "  when  nothing  is  applied,  or  by  using  some 
indifferent  object  in  place  of  the  one  which  the  patient  is  expecting,  as 
the  finger-tip,  requiring  him  at  the  same  time  to  tell  what  it  is. 

The  attending  conditions  must  be  usual  and  natural.  It  is  useless  to 
test  the  sensibility  of  chilled  extremities  or  to  expect  reliable  replies 
from  the  stuporous.  In  many  instances,  moreover,  there  is  much  sensory 
disturbance  without  the  patient  being  aware  of  it,  as  in  hysteria ;  or 
there  may  be  dissolution  of  the  various  qualities  of  the  sense  of  touch 
that  has  not  specially  attracted  his  attention,  as  in  syringomyelia. 

The  tactile  sense  enables  us  to  recognize  the  contact  of  objects  with 
the  skin.  In  a  crude  way  its  delicacy  may  be  tested  by  stroking  with 
a  feather  or  flake  of  cotton,  by  touching  lightly  the  ends  of  hairs  grow- 
ing on  the  limbs,  or  by  ruder  contacts  when  the  sense  is  found  blunted. 
An  instrument  called  an  esthesiometer,  consisting  of  two  movable  points, 
is  frequently  employed  in  testing  this  element  of  the  sense  of  touch.  A 
pair  of  compasses  answers  the  purpose.  Observations  are  made  as  to 
the  least  distances  at  which  two  blunted  points  are  both  recognized  when 
brought  into  contact  with  the  skin  at  the  same  time,  and  in  a  line  parallel 
to  the  course  of  the  nerve  supplied  to  the  part.  These  distances  vary 
widely,  as  between  the  tip  of  the  tongue  or  finger  and  the  dorsum  of  the 
body.  The  following  average  measurements  will  serve  as  a  standard  of 
comparison,  or  if  the  sensory  disturbance  be  limited  to  one  side  of  the 
body,  the  opposite  corresponding  area  will  furnish  a  better  guide.  Dif- 
ferences, to  be  significant,  must  be  about  double  those  here  indicated  : 


Table  Showing  Oedinaky  Distances  at  which  Two  Points  are 

Recognized. 

Tip  of  tongue    ....  1  mm.  (1-25  in.)        Tip  of  toes,  cheeks,  eyelids  .    .  12  mm. 

Tip  of  fingers    ...    .2  "  Temple      13  " 

Lips 3  "  Back  of  hands 30  " 

Dorsal   surface   of   fin-  Neck 35  " 

gers 6  "  Forearm,  leg,  back  of  foot    .    .40  " 

Tip  of  nose 8  "  Back 60-80  " 

Forearm 9  "  Arm  and  thigh 80  " 

Another  means  of  testing  the  tactile  sense  is  to  place  variously- 
shaped  objects  on  the  skin  and  to  ask  a  description  of  them,  or  to  trace 
letters  and  numerals  with  a  blunt  point.  The  so-called  stereognostic 
sense  is  a  complicated  faculty,  embracing  many  or  all  of  the  elements 
of  tactile  sense.  All  those  perceptions  of  the  qualities  of  an  object 
received  through  the  sense  of  touch  make  up  a  complex  enabling  its 
recognition  if  repeated  with  sufficient  frequency.  Thus  we  can  with 
closed  eyes  recognize  by  touch  all  familiar  objects.  In  certain  brphi- 
states,  particularly  those  involving  the  sensori-motor  cortex,  and  perhaps 
in  a  more  limited  sense  the  parietal  area,  the  faculty  is  lost,  constituting 
a  state  of  astereognosis  or,  better,  stereoagnosis. 


SENSOBY  CONDITIONS.  51 

The  pain  sense  may  be  readily  investigated  by  using  a  pricking  point, 
but  it  mast  not  be  too  fine.  A  pointed  quill  or  toothpick  answers  well 
except  in  marked  analgesia.  The  patient  is  required  to  state  whether  a 
touch  or  a  painful  prick  is  recognized. 

The  pressure  sense,  which  is  not  of  great  importance,  is  tested  by 
placing  on  the  skin  objects  of  the  same  size  and  external  character,  such 
as  balls  of  equal  size  but  variously  weighted.  A  spring  instrument 
fitted  with  an  index  and  a  scale  is  also  used.  .  Where  the  extremities  are 
thus  tested  it  is  necessary  to  so  support  them  that  no  notion  of  the  pres- 
sure be  given  by  motions  communicated  to  the  joints  and  muscles. 

The  thermic  sense  can  be  quickly,  though  roughly,  examined  by 
first  breathing  and  then  blowing  on  a  part.  In  order  to  estimate  it  more 
exactly  it  is  best  to  use  test-tubes  filled  with  water  at  various  known 
temperatures.  Every  test  requires  that  considerable  surface  come  in 
contact  with  the  skin  for  a  few  moments,  as  the  integument  must  gain 
or  lose  heat  proportionately  before  the  exact  degree  of  temperature  is 
appreciated.  Within  a  few  degrees  of  the  ordinary  body  surface-tem- 
perature— namely,  80°  to  86°  F. — slight  changes  are  not  recognized  in 
health.  Below  this  to  freezing  and  above  it  to  about  150°  F.  a  varia- 
tion of  two  to  five  degrees  is  readily  perceived.  Inability  to  recognize 
temperatures  from  60°  to  70°  as  cool  and  86°  to  100°  as  warm  may 
be  considered  abnormal.  Such  a  condition  is  denominated  thermo-anes- 
thesia,  and,  when  complete,  ther mo-analgesia.  Those  parts  of  the  skin 
possessing  the  most  acute  tactile  sense  are  also  most  sensitive  to  heat. 

The  term  muscular  sense  is  used  in  two  ways  : 

First.  It  refers  to  the  sensations  arising  in  muscles  themselves.  In 
a  painful  degree  this  occurs  in  a  cramp  or  in  a  tetanizing  faradic  con- 
traction. The  tension  on  muscles  and  tendons  is  no  doubt  subconsciously 
recognized  by  the  coordinating  mechanism,  and  it  is  only  when  these 
sensations  are  greatly  intensified  that  we  take  conscious  note  of  them. 

Second.  By  muscular  sense  we  refer  to  the  ability  to  estimate  the 
weight  of  various  bodies.  This  ability  is  to  so  great  an  extent  a  result  of 
practice  and  varies  so  widely  among  healthy  persons  that  unless  great 
differences  of  weight  are  not  appreciated  the  test  gives  little  information 
of  value.  Balls,  such  as  those  employed  in  the  pressure  test,  can  be 
used,  or  attempts  made  to  repeat  a  fixed  number  on  the  dynamometer. 
When  the  sensation  of  tendons,  joints,  and  muscles  is  blunted,  not  only 
is  the  muscular  sense  reduced,  but  knowledge  of  the  position  of  the 
limbs  is  wholly  or  in  part  wanting  and  ataxia  is  present,  as  described 
under  Errors  of  Motility. 

In  certain  conditions,  notably  tabes,  sensation  is  retarded  and  the 
reaction  time  is  greatly  prolonged.  A  painful  impression,  as  by  the 
prick  of  a  pin  on  the  foot,  may  not  be  recognized  and  responded  to  for 
several  seconds.  In  such  cases  the  transmission  of  all  touch  sensations 
is  slow.  We  prick  the  patient,  having  instructed  him  to  say  "  now  " 
as  soon  as  he  feels  the  needle,  and  note  the  interval,  which,  in  health,  is 
a  small  fraction  of  a  second  only.  The  intelligence  and  promptness  of 
the  patient  materially  affect  the  apparent  length  of  intervening  time. 
In  some  instances  a   single  prick  is  recognized  as  two  or  more,  or  a 


52 


NERVOUS  AND  MENTAL  DISEASES. 


Auriculotemporal  3  V. 

Great  occipital 

Lacrimal  1  V. 

Temporomalar  2  V. 

Small  occipital  C.  P. 

Great  auricular  C.  P. 


Supraclavicular 

C.  P. 

Acromial  branch 

Middle  branch 


Circumflex  E.  P. 
Intercostohumeral 

Nerve  of  Wrisberg 

B.  P. 
External  cutaneous 
of  musculospiral 
B.  P. 

Internal  cutaneous 
B.  P. 

Musculocutaneous 
B.  P, 


Median 
B.  P. 


Ulnar  B.  P, 
External  cutaneous  L.  P. 


Branches  from  external 
pofjliteal  S.  P. 


Musculocutaneous  S.  P. 

External  saphenous  S.  P. 
Anterior  tibial  S.  P. 


Supra-orbital  1  V. 

Supratrochlear  1  V. 
Intratrochlear  1  V. 
Nasal  1  V. 

Infra-orbital  2  V. 
Buccals  V. 
Mental  3  V. 

Superficial  cer\'ical  C.  P. 


Sternal  branch 


Anterior  branches  of  intercostal 
nerves 


Lateral  branches  of  intercostal 
nerves 


Diohypogastric  L.  P. 
Dorsalis  penis  of  pudic  S.  P. 
Ilioinguinal  L.  P. 

Genitojrural  L.  P. 
Jliddle  cutaneous  L.  P. 
Internal  cutaneous  L.  P. 


Internal  saphenous  L.  P. 


Fig.  15.— Cutaneous  distribution  of  nerves  (after  Flower). 


SENSORY  CONDITIONS. 


Great  occipital,  posterior  branch  of 
second  cervical 


Third  cervical 


Posterior  branches  of  spinal  nerves 


Lateral  branches  of  intercostal  nerves 

Iliac  branch  of  ilio-inguinal  L.  P. 
Second  lumbar 

Inferior  hemorrhoidal  of  pudic  S.  P. 

Superticial  perineal  of  pudic  and 
inferior  pudendal  of  small 
sciatic  S.  P. 

Interior  gluteal  of  small  sciatic  S.  P. 


Internal  cutaneous  L.  P. 


Internal  saphenous  L.  P. 


Auriculotemporal  3  V. 
Small  occipital  C.  P. 

Great  auricular  C.  P. 


Supraclavicular 
—     C.  P.,  acromial 
branch 

Second  dorsal 
Circumtlex  B.  P. 


Intercostohu  m  eral 

Internal  cutaneous 
of  musculospiral 
B.  P. 

Nerves  of  Wrisberg 

External  cutaneous 
of  musculospiral 
B.  P. 

Internal  cutaneous 
B.  P. 

Musculocutaneous 
B.  P. 


Radial  B.  P. 


Ulnar  B.  P. 


External  cutaneous  L.  P. 


Branches  from  external 
popliteal  S.  P. 


External  saphenous  S.  P. 


Posterior  tibial  S.  P. 


Fig.  16. — Cutaneous  distribution  of  nerves  (after  Flower). 


54  NERVOUS  AND  MENTAL  DISEASES. 

painful  impression  is  felt  at  a  distant  point, — a  referred  sensation, — or 
on  the  opposite  side  of  the  body  at  a  symmetrical  spot, — allocheiria. 

The  sensibility  of  bones  and  joints  may  be  roughly  but  readily  tested 
by  resting  the  stem  of  a  vibrating  tuning-fork  at  those  points  where  they 
are  subcutaneous.     Informally  one  perceives  the  communicated  thrill. 

Complete  loss  of  sensation  is  properly  termed  anesthesia.  Through 
usage  this  word  signifies  any  degree  of  blunted  sensation,  and  is  qualified 
by  adjectives  such  as  partial,  complete,  or  slight,  as  the  case  may  require, 
and  further  limited  by  such  combinations  as  muscle,  anesthesia,  tactile, 
thermic,  and  joint  anesthesia.  The  loss  of  the  sense  of  pain  is  called 
analgesia,  and  this  word  is  compounded  in  a  similar  way. 

Sensation  may  also  be  intensified,  giving  rise  to  hyperesthesia  and 
hyperalgesia.  These  conditions  are  made  evident  by  the  usual  tests,  and 
require  no  extended  review. 

In  addition  there  are  a  host  of  purely  subjective  sensory  disturbances, 
described  as  sensations  of  heat  or  cold,  numbness,  prickling,  crawling, 
creeping,  tingling,  heaviness,  deadness,  etc., — paresthesice.  Areas  so 
affected  may  show  no  alteration  of  sensibility  when  actually  tested. 
Paresthesiae  usually  are  symptomatic  of  general  nutritional  states  or  of 
the  so-called  neuroses. 

Having  determined  a  localized  dysesthesia,  or  condition  of  disturbed 
sensation,  it  is  of  the  first  diagnostic  importance  to  outline  it  as  accu- 
rately as  possible.  Sensation  may  be  disturbed  by  lesions  which  involve 
sensory  paths  at  any  point  from  the  cerebral  cortex  to  the  terminal 
organs  in  the  muscles  and  skin.  The  dysesthesic  area,  however,  presents 
a  different  and  distinctive  outline  as  various  levels  are  injured. 

If  a  nerve-trunk  or  branch  be  injured  by  traumatism  or  disease, 
anesthesia  will  be  limited  to  the  corresponding  anatomical  cutaneous 
distribution.  Per  contra,  if  such  anatomical  area  be  found  to  be  anes- 
thetic, the  inference  is  at  once  justified  that  a  peripheral  lesion  is 
present.  As  soon  as  the  sensory  nerve-fibers  reach  the  spinal  cord  they 
ramify  so  widely  in  the  various  segments  that  it  w^ould  be  impossible  for 
any  spinal  disease  or  injury  to  select  a  given  number  from  all  others. 
Figures  15  and  16  show  these  sensory  areas,  and  should  be  carefully 
studied. 

If  the  spinal  cord  undergo  a  complete  cross-lesion  or  division,  we 
have  loss  of  sensation  in  the  nerve-area  below  the  upper  level  of  the 
injury.  Now,  the  distribution  of  anesthesia  has  relation  to  the  cord- 
segments,  and  not  to  the  nerve-trunks.  For  a  practical  understanding 
of  this  fact  it  is  necessary  to  recall  that  the  body,  from  one  end  of  the 
vertebral  chain  to  the  other,  is  made  up  of  a  number  of  similar  seg- 
ments or  links,  all  more  or  less  perfectly  represented  in  the  skeleton, 
muscles,  viscera,  skin,  and  nervous  apparatus.  In  the  dorsal  region  the 
plan  is  comparatively  simple,  but  as  the  limbs  are  reached  it  is  greatly 
complicated.  If  vertical  sections  of  the  body  w^ere  to  be  made  approx- 
imately on  these  segmental  lines,  it  would  be  requisite  to  place  it  in  the 
all-fours  position,  making  the  coccygeal  end  of  the  vertebral  column  the 
posterior  or  last  segment.  The  diagrams  of  Starr  (Fig.  17)  clearly  show 
this,  and  the  difference  between  the  spinal-segment  area  and  the  nerve- 
trunk  representation  of  sensation  is  apparent.      It  at  once  becomes  plain, 


SENSOEY  CONDITIONS. 


55 


when  we  find  an  anesthetic  area  corresponding  to  a  spinal-segment  level 
that  the  lesion  is  in  the  cord  and  at  a  particular  part  of  the  cord  ;  more- 
over, that  its  upper  level  corresponds  to  the  upper  level  of  the  anesthetic 
zone.  Just  above  this  level,  owing  to  the  irritation  of  the  sensory  roots 
of  the  spinal  nerves,  there  commonly  is  a  band  or  girdle  of  hyperesthe- 
sia bordering  the  anesthetic  area.  This  also  serves  to  indicate  the  upper 
limit  of  the  spinal  lesion. 

Should  the  cord  injury  involve  only  one  lateral  half  of  the  trans- 
verse cord-section,  the  symptom  complex  of  Brown-Sequard  paralysis 
develops.     The  hemicordal  lesion  causes  complete  loss  of  power  on  the 


Fig.  17. — Cutaneous  areas  related  to  the  spinal-cord  segments  (Starr). 


same  side  as  the  lesion  in  all  parts  below  that  point.  There  is  also 
usually  a  slight  loss  of  power  below  the  lesion  upon  the  opposite 
side.  Anesthesia  is  complete  on  the  side  opposite  the  lesion,  below 
its  level.  This  is  due  to  the  fact  that  the  sensory  paths,  upon 
entering  the  cord,  cross  to  the  opposite  side,  and  then  proceed  up- 
ward. The  sensory  roots  entering  the  cord  at  the  point  of  lesion 
are  destroyed  ;  so  that  there  is  upon  the  same  side  of  the  body  a  band 
of  cutaneous  anesthesia  which  marks  the  exact  level  of  the  lesion  of  the 
cord.      It  varies  vertically  in  relation  to  the  extent  of  cord  destroyed. 


56 


NERVOUS  AND  MENTAL  DISEASES. 


The  sensory  roots  entering  the  cord  at  the  upper  margin  and  at  the 
lower  limit  of  the  lesion,  irritated  thereby,  furnish,  both  above  and  below 
the  band  of  anesthesia,  a  varying  band  of  hyperesthesia  on  the  paralyzed 
side.  On  the  opposite  or  anesthetic  side  there  is  also  a  band  of  hyper- 
esthesia due  to  the  irritation  of  the  sensory  root  as  it  crosses  into  the 

contralateral  half  of  the  cord  at  the  upper 
level  of  the  destructive  process.  This  sen- 
sitive area  is  always  a  little  below  the  hyper- 
esthetic  band  of  tbe  paralyzed  side.  The 
accompanying  scheme  (Fig.  18)  shows  the 
sensory  tracts  and  the  involvement  of  the 
sensory  roots  upon  each  side.  The  distri- 
bution of  sensory  and  motor  disturbance  is 
shown  in  figures  18  and  19.  In  addition, 
the  reflexes  are  increased  below  the  lesion 
on  the  paralyzed  side,  but  abolished  at  the 
level  and  throughout  the  vertical  extent  of 
the  lesion. 

Lesions  of  the  internal  capsule  involving 
its  posterior  sensory  portion  give  rise  to 
hemianesthesia  embraciuo:  more  or  less  accu- 
rately  and  completely  one-half  of  the  head 
and  trunk  with  the  limbs  on  the  same  side. 
It  is  usually  associated  with  similarly  dis- 
tributed motor  paralysis. 

In  the  cerebral  cortex  cutaneous  sensory 
representation  corresponds  probably  quite 
closely  to  the  motor  fields.  Cortical  lesions 
in  this  field  lead  to  paresthetic  disturbances 
of  sensation  that  have  functional  rather 
than  anatomical  limits,  just  as  electrical 
stimulation  of  the  cortex  leads  to  pur- 
posive or  grouped  muscular  movements, 
and  not  to  those  subserved  by  any  spinal 
segment  or  nerve-trunk.  In  hysterical 
anesthesia  a  similar  distribution  is  noted, 
the  affected  area  often  having  the  outline 
of  the  surface  covered  by  a  glove,  sock,  or 
sleeve,  and  limited  with  precision  to  the 
functional  area  that  is  the  object  of  the 
patient's  attention  or  solicitude. 

Pain  as  a  symptom  is  worthy  of  care- 
ful study.  The  first  inquiry  should  be  as  to  its  character.  Is  it  con- 
stant or  intermittent?  is  it  periodical?  does  it  appear  at  a  regular  time 
daily,  or  every  other  day,  or  is  it  worse  at  any  particular  time  of  the 
day?  Then,  is  it  sharp,  lancinating,  or  dull  and  heavy?  Note  exactly 
the  distribution  of  the  pain.  Observe  if  it  is  limited  to  the  cutaneous 
area  of  a  peripheral  nerve  or  if  it  has  the  distribution  of  a  spinal  segment. 


Fig.  18. — Scheme  representing 
coid-leslon  and  effects  in  Bro«n- 
Sequai'd  paralysis  (after  Brissaud). 
CSO,  Left  .sensitive  tract;  CSD,  right 
sen.sitive  tract;  A,  B,  C,  D,  lesioa 
involving  the  left  half  of  tlie  coid  ; 
S,  8,  S,  sensory  roots  from  right  siile 
of  bodv  ;  Z,  Z,  Z,  sensory  roots  from 
left  side  of  body  ;  Zi,  Z-,  and  S-'  are 
irritated  only  at  the  points  A,  B,  C, 
and  their  peripheral  area  is  hyperes- 
theiic:  Z-  is  divided  and  its  skin 
area  is  anesthetic  on  the  .same  side 
as  the  lesion.  Corresponding  to  S* 
and  all  the  roots  below  arising  from 
the  right  side  of  the  body,  there  is 
anesthesia. 


SENSORY  CONDITIONS. 


57 


In  every  instance  of  pain,  seek  for  tenderness.  The  painful  part,  during  the 
presence  of  protracted  pain,  is  almost  invariably  sensitive.  When  lightly 
touched,  certain  portions  of  the  hyperesthetic  surface  will  be  found 
especially  affected.  These  maximal  points  of  pain  are  usually  situated 
where  the  sensory  nerves  become  superficial  or  pass  bony  prominences. 

It  is  best  to  carefully  outline  these  sensitive  areas  with  a  blunt 
point,  as  the  head  of  a  large  pin,  and  not  trust  to  the  rough  gestures  and 
statements  of  patients.  In  other  instances  the  tenderness  can  only  be 
detected  by  deep  pressure.  For  instance,  intercostal  neuralgia  produces 
superficial  tenderness ;  pleurisy 
is  marked  by  tenderness  on  deep 
pressure  or  percussion.  To  Dana 
and  Head^  we  owe  a  definite 
knowledge  of  the  relation  of 
cutaneous  sensitiveness  and  pain 
to  visceral  disease.  Head's  work, 
abundantly  verified,  clearly  shows 
that  the  superficial  surface  of  the 
body  is  in  relation  with  the  vis- 
cera through  the  spinal  centers. 
Disease  arising  in  the  visceral 
portion  of  a  vertebral  segment 
gives  rise  to  pain  referred  to  the 
body  or  somatic  area.  Similarly, 
disease  of  the  spinal  segments 
gives  rise  to  pain  and  other 
sensory  disturbances  in  the  skin, 
as  already  pointed  out,  and  in 
the  associated  viscera.  Macken- 
zie ^  insists  that  the  viscera  are 
insensitive  and  that  pain  is  felt 
through  the  cerebrospinal  nerves 
alone.      That,    for    instance,    the 

well-known  tenderness  over  the  liver  readily  elicited  by  pressure  in  disease 
of  that  organ  is  in  fact  confined  to  the  skin  and  muscles  of  the  abdominal 
wall.  These  areas,  as  mapped  out  by  Head,  with  their  maximal  points 
for  the  body  and  limbs,  are  presented  in  figure  20  (A,  B,  C),  and  the 
following  table  shows  the  relation  of  the  viscera  to  these  areas  : 

Table  Showing  Areas  of  Pain  Referred  from  Visceral  Disease. 

Heart. — First,  2cl,  3d,  dorsal  segments. 
Lungs.— Ynst,  2d,  3d,  4th,  5th  dorsal. 
Stomach. — Sixth,  7th,  8th,  9th  dorsal ;  cardiac  end  from  6th  and  7th. 

Pyloric  end  from  9th. 
Intestines. — (A)  Down  to  upper  part  of  rectum. 

Ninth,  10th,  11th,  and  12th  dorsal. 
(B)  Rectum. 

Second,  3d,  and  4th  sacral. 
Liver  and  Gall-bladder. — Seventh,  8th,  9th.  10th  dorsal. 
Perhaps  6th  dorsal. 


Fig.  19. —Application  of  the  scheme  to  the  trunk 
(Brissaud).  Anesthesia  is  indicated  by  horizontal 
lines  ;  hyperesthesia  by  diagonal  lines. 


iHead,  "Brain,"  Ivi. 


2  "Brain,"  1902. 


58 


NERVOUS  AND  MENTAL  DISEASES. 


•«.   .    N      "N        !^  -^        I, 


illlNllllllllllllflr-i 


if^'l^'f^'f^ 


-Q     ^ 


q         '^C^'c:!S^^(^^' c^  c:^l^iH^iQ 


^X    'S.  ">•    ^     ^ 

'^'  9^  C5  ^  ^ 


c:i  f::^  Q  Q  q 


--ri    -^ 


SENSOEY  CONDITIONS. 


59 


Kidney  and  Ureter.  — Tenth,  1 1th,  and  ]  2th.    The  nearer  the  lesion  Has  to  the  kidney, 
the  more  is  the  pain  and  tenderness  associated  with  the  10th  dorsal.     The 
lower  the  lesion  in  the  ureter,  the  more  does  the  1st  lumbar  tend  to  appear. 
Bladder. — (A)  Mucous  membrane  and  neck  of  bladder. 
First,  2d,  3d,  4th  sacral. 
(B)  Overdistention  and  ineffectual  contraction. 
Eleventh  and  12th  dorsal  and  1st  lumbar. 
P)-ostate.— Tenth,  11th,  12th  dorsal. 

First,  2d,  3d  sacral  and  5th  lumbar. 
Epididipnis. — Eleventh  and  12th  dorsal  and  1st  lumbar. 
Testis.  —Tenth  dorsal. 
Ovary.  ■ — Tenth  dorsal. 

Appendac/es,  etc. — Eleventh  and  12th  dorsal  and  1st  lumbar. 
Uterus.— (A)  In  contraction. 

Tenth,   Uth,  12th  dorsal  and  1st  lumbar. 
(B)  Os  uteri. 

First,  2d,  3d,  4th  sacral,  and  5th  lumbar  very  rarely. 

A  farther  point  elucidated  by  the  same  author  is  the  relation  of  head 
pains  and  aches  to  vi.sceral  disturbances.  Such  pains  and  aches  are 
marked  by  definite  areas  of  sensitiveness  when  at  their  height  and  by  ten- 


FRONTONASAL 


IIIDORBITAL  MlOORBlTAL 

Frontotemporal 

-Temporal 

Frontotemporal 

Temporal 


Vertical 
Parietal 


Occipital 
Mandibular 


-Superior  Laryngeal 

Inferior  Laryngeal 


Superior  Laryngeal 
Inferior  Laryngeal 


Fig.  21. 


Fig.  22. 


Parietal 


Occipital 


Fig.  23. 
Figs.  21,  22,  and  23. — Maximal  points  of  referred  and  associated  pain  on  the  head  and  face. 


60 


NERVOUS  AND  MENTAL  DISEASES. 


der  maxima.  These  maxima,  as  those  upon  the  trunk,  are  practically 
the  tender  points  of  Valleix.  They  are  much  more  persistent  than  the  ten- 
der areas,  which  usually  are  only  well  marked  when  the  pain  is  severe 
and  gradually  subside  concentrically,  leaving  the  maxima.  On  the  head 
and  face,  as  on  the  trunk  and  limbs,  these  pain-areas  have  segmental  dis- 
tribution and  in  no  manner  correspond  to  the  peripheral  nerv^e-supply. 

Figures  21,  22,  and  23  show  the  cephalic  maximal  points,  and  the 
following  table  shows  the  relation  of  the  body- viscera  to  these  head- 
points  and  also  to  the  body-areas  : 

Table  Showing  Associated  Painful  Aeeas  on  the  Head  Eelated  to 
Visceral  Disease  in  the  Body. 


Area  on  Body. 

Associated  Area  on 
Scalp. 

Organs  in  Particular  Relation  to 
THESE  Areas. 

Cervical,  3 

Frontonasal  (?  ros- 
tral). 

Apices  of  lungs.     Stomach.     Liver. 

Cervical,  4 

Frontonasal. 

Dorsal,  2 

Midorbital. 

Lung.       Heart.       Ascending    arch    of 
aorta. 

Dorsal,  3 

Midorbital. 

Lung.     Arch  of  aorta. 

Dorsal,  4 

Doubtful. 

Lung. 

Dorsal,  5 

Frontotemporal. 

Lung.     Heart. 

Dorsal,  6 

Frontotemporal. 

Lower  lobe  of  lungs.     Heart. 

Dorsal,  7 

Temporal. 

Bases  of  lungs.     Heart.     Stomach. 

Dorsal,  8 

Vertical. 

Stomach.     Liver.     Upper  part  of  small 

intestine. 

Dorsal,  9 

Parietal. 

Stomach.    Upper  part  of  small  intestine. 

Dorsal,  10 

Occipital. 

Liver.     Intestine.     Ovaries.     Testes. 

Dorsal,  11 

Occipital. 

Intestine.      Fallopian   tubes.      Uterus. 
Bladder. 

Dorsal,  12 

Occipital. 

Intestine.     Uterus,  etc. 

In  like  manner  disease  within  the  head  and  neck  has  its  referred  pain, 
associated  tender  area,  and  maximal  point.    They  may  be  thus  tabulated  : 


Organ  at  Fault. 


Ciliary  muscle   (errors 

of  accommodation)  . 

Cornea    ....... 

Iris 


Vitreous  (glaucoma)    . 
Retina  ... 

Teeth  (upper  incisors)  . 
Upper  canine  and  first 
bicuspid         .... 
Upper  second  bicuspid 

Upper  first  molar      .    . 
Upper  second  and  third 

molars     .... 
Lower  incisors,  canine, 

and  first  bicuspid     . 
Lower  second  bicuspid 


Maxima  of  Pain 
AND  Tenderness. 


Midorbital. 

Frontonasal. 

Fronto-temporal . 
Temporal  and 
maxillary. 

Temporal. 

Vertical. 

Frontonasal. 

Nasolabial. 
Temporal      or 

maxillary. 
Maxillary. 

Mandibular. 

ilental. 
Mental  or  hyoid. 


Organ  at  Fault. 


Lower  first  and  second 
molars 

Lower  third  molar  .  . 
Membrani  tympani  . 
Middle  ear 

Tongue,  tip 

Tongue,  lateral  part  . 
Tongue,  base    .... 

Tonsil 

Nose,  olfactory  portion 

Eespiratory      portion 

and  posterior  nares  . 

Larynx 


Maxima  of  Pain  and 
Tenderness. 


Hyoid  and  pain  in 

the  ear. 
Superior  laryngeal. 
Hyoid. 
Vertical  and  behind 

ear. 
Mental. 

In  ear  and  hyoid. 
Superior  laryngeal. 

Occipital. 
In  ear  and  hyoid. 
Frontonasal      and 

midorbital. 

Nasolabial. 
Superior  and    infe- 
rior laryngeal. 


THE  SPECIAL  SENSES.  61 

Brain  disease  presents  pain  of  two  varieties  :  First,  When  the  me- 
ninges are  involved  there  is  a  h)cal  pain  with  tenderness  on  pressure  and 
percussion.  Second.  In  conditions  of  intracranial  pressure  and  disease 
of  the  brain  proper  there  is  superficial  tenderness  and  the  pain  is  widely 
distributed.  In  the  second  class  of  cases  pain  is  usual  in  the  brow, 
vertex,  occiput,  back  of  the  neck  and  shoulder,  and  similarly  distributed 
tenderness  is  common. 

The  descriptions  of  some  pains  by  patients  are  classical  and  almost 
diagnostic.  The  lightning  pains  of  tabes,  the  gnawing  pains  of  rheu- 
matism, the  burning  pains  of  neuritis,  the  girdle  pains  of  spinal  disease, 
the  lead-cap  pressure  pain  of  neurasthenia,  the  pain  under  the  breast 
and  in  the  groin  in  hysteria,  the  daily  recurring  brow  pain  of  malaria, 
and  the  nocturnal  pains  of  syphilis  have  a  significance  quite  their  own. 
The  circumstances  under  which  pains  occur  often  throw  light  upon  their 
nature.  Sciatica  and  lumbago  are  provoked  by  motion  and  allayed 
by  rest.  The  head  pains  of  eye-strain  bear  a  distinct  relation  to  ocular 
employment.  Neurasthenic  pains  always  increase  under  fatigue  or  de- 
pressing— that  is,  exhausting — emotions.  A  pain  that  is  practically 
circumscribed  has  a  tendency  to  spread  to  associated  organs  and  to 
neighboring  areas  after  long  duration,  general  depression,  or  the  onset  of 
any  marked  physical  illness.     It  thus  becomes  generalized. 


CHAPTER  VII. 
THE  SPEQAL  SENSES. 

Sight. — The  eye  presents  many  interesting  and  valuable  symptoms 
in  a  wide  variety  of  nervous  aifections.  Its  systematic  examination 
should  be  a  part  of  the  case-taking  in  every  instance. 

The  lids  on  the  two  sides  may  show  a  diiference  in  the  palpebral 
opening  due  to  paralysis  or  spasm.  Exact  symmetry  is  the  rare  excep- 
tion in  health,  but  any  marked  acquired  inequality,  unless  due  to  scars 
or  local  conditions,  such  as  conjunctivitis,  irritation,  swelling,  new 
growths,  etc.,  implies  some  variation  of  muscular  control  or  nerve-supply. 
A  falling  of  the  upper  lid,  or  ptosis,  is  a  common  early  symptom  of  tabes 
and  syphilitic  brain  disease,  while  in  a  facial  palsy  an  inability  to  close 
the  lids  is  a  marked  sign.  From  the  same  cause  the  lower  lid  may  be 
everted.  An  acquired  prominence  of  the  eyeball  may  greatly  enlarge 
the  palpebral  opening.  In  exophthalmic  goiter  the  lids  frequently  fail 
to  follow  the  upward  and  downward  excursion  of  the  ocular  globe.  This 
is  not  entirely  due  to  the  protrusion  of  the  eye,  as  it  has  been  noted  in  the 
absence  of  this  condition,  and  in  some  instances  is  congenital.  In  hysteria 
a  condition  often  confounded  with  ptosis,  but  really  an  orbicular  spasm,  is 
sometimes  encountered.  Blepharospasm  as  a  limited  facial  tic  is  a  very 
common  affection.  Many  states  of  brain  and  optic-nerve  disturbance  are 
marked  by  the  closed  lids  oi photophobia,  which  should  not  be  confounded 
with  that  arising  from  inflammatory  conditions  of  the  lids,  cornea,  or  iris. 

Attention  has  already  been  directed  to  the  reactions  and  reflexes  of 


62  NERVOUS  AND  J^IENTAL  DISEASES. 

the  pupils.  Irregularities  in  their  outline  or  inequalities  in  size  are  to  be 
carefully  noted,  but  pupillary  deformities  from  antecedent  inflammatory 
processes  or  injuries  followed  by  synechia  must  not  be  mistaken  for  per- 
verted innervation.  Paralysis  of  the  pupillary  muscles  is  iridopjlegia  ; 
paralysis  of  the  ciliary  muscles — cydopAegio. — is  marked  by  the  loss  of  the 
function  of  visual  accommodation.  They  are  usually  found  together, 
and  then  constitute  ophthalmoplegia  interna.  Paralysis  of  the  external 
muscles  of  the  eye — namely,  the  recti,  obliqui,  patheticus,  and  the  eleva- 
tor of  the  lid — is  denominated  opjhthalmopjkgia  externa. 

The  external  muscles  receiving  their  innervation  from  three  sources, 
the  third,  fourth,  and  sixth  cranial  nerves,  are  ver}'  frequently  involved 
singly  or  in  groups.  This  gives  rise  to  various  deviations  of  the  visual 
axes  of  the  eyes  or  loss  of  power  in  directing  them  conjointly  in  some 
given  direction,  with  resulting  indistinctness  of  vision  or  complete  double 
vision, — diplopjia.  Parely  a  monocular  dipjlopia  is  encountered  as  a 
pure  hysterical  symptom,  but  it  may  be  the  result  of  defective  curva- 
tures in  the  ocular  media,  as  in  corneal  deformities.  The  special 
examination  to  determine  the  muscle  or  muscles  at  fault  in  these  squint 
conditions  will  be  taken  up  under  the  consideration  of  the  diseases  of 
the  cranial  nerves  distributed  to  the  ocular  apparatus.  Great  and  un- 
warranted stress  has  been  put  by  some  enthusiasts  upon  a  condition  of 
a  lack  of  balance  among  the  extrinsic  muscles  of  the  eye,  named  hetero- 
jjhoria.  Of  much  greater  importance  are  errors  of  refraction  and  ac- 
commodation in  myopia,  hyperopia,  and  astigmatism.  They  are  attended 
bv  conscious  or  unconscious  efforts  at  clear  vision,  constituting  a  condi- 
tion of  eye-strain  that  may  furnish  an  active  source  of  nerve  Avaste. 
Extreme  and  constant  deviations  from  the  normal  control  of  the  extrinsic 
eye  muscles  can,  no  doubt,  act  in  the  same  way,  but  slight  variations  in 
conditions  of  ill-health  are  commonly  the  result  and  not  the  cause  of 
such  states.  As  the  general  state  fluctuates,  they  correspondingly  vary 
for  better  or  worse. 

Vision  can  be  readily  tested  by  the  t^^pes  of  Jaeger,  and  when  seriously 
defective,  by  having  the  patient  count  fingers  held  in  a  good  light  against 
a  dark  background.  Astigmatic  error  is  roughly  and  quickly  shown  by 
the  use  of  the  numerous  familiar  charts  for  the  purpose.  Por  further 
details  reference  should  be  had  to  systematic  works  on  the  eye. 

The  opjhthalnioscopje  is  one  of  the  most  important  instruments  in  the 
diagnostic  outfit  of  the  neurologist.  An  ability  to  readily  examine  the 
ocular  fundus  at  the  bedside  or  elsewhere  is  one  of  his  most  needful 
accomplishments.  Familiarity  with  the  normal  ophthalmoscopic  picture, 
supplemented  by  experience  in  recognizing  vascular  disturhanees,  choked 
disc,  and  atropjhy  of  the  optic  nerve,  will  often  render  positive  a  host  of 
otherwise  obscure  indications. 

The  visual  field  is  the  area  over  A\'hich  olyects  are  visible  while  the 
eye  is  fixed.  In  health  its  limits  are  tolerably  uniform,  being  modified 
above  and  within  by  the  brow  and  nose.  In  this  field  colors  of  objects 
are  recognized  by  the  normal  eye  at  various  distances  and  in  a  certain 
order  from  the  fixed  pjoint  upon  wliich  the  gaze  is  directed.  From 
without  inward  come  white,  blue,  yellow,  orange,  red,  green,  and  violet. 


THE  SPECIAL  SENSES. 


63 


The  form  of  the  test-object  is  perceived  before  its  color  is  apparent, 
as  is  shown  by  the  chart  (Fig.  24). 


Fig.  24.— Normal  yisual  fields  for  form  and  the  various  colors  (after  Souques).    Form  field  unshaded. 
The  blue  field  is  inclosed  thus ,  the  red  field  thus  +  +  +  +,  the  green  field  thus i V- 


The  visual  field  is  peculiarly  modified  by  various  diseases.  In  pro- 
nounced hysteria  we  have  usually  a  concentric  uniform  reduction  of  the 
field.  The  color-fields  may  be  reduced  almost  to  the  fixing-point  or 
entirely  obliterated.  Even  more  characteristic  is  a  rearrangement  of 
them  so  that  the  red  field  overlaps  or  completely  surrounds  the  blue. 
The  relation  of  red  and  blue  is  therefore  to  be  remembered.  In  neuras- 
thenia the  fields  are  frequently  much  reduced,  and  fatigue  conditions 
promptly  increase  their  contraction.  In  well-marked  cases  the  efforts 
put  forth  by  the  patient  in  responding  to  the  tests  may  serve  to  greatly 
increase  the  reduction  of  the  fields  within  a  few  moments.  In  tobacco 
and  alcohol  poisoning  and  other  toxic  conditions  the  fields  are  sometimes 
greatly  contracted  and  present  blind  areas,  or  scotomata.  Destructive 
diseases  occurring  back  of  the  globe  may  cut  off  a  portion  of  the  field, 
producing  hemiopia,  scotomata,  central  blindness,  concentric  blindness,  or 
blindness  in  a  quadrant  of  the  field,  as  the  fibers  or  centers  related  to 
the  given  area  are  involved. 

To  test  the  field  of  vision  a  perimeter  is  of  service,  and,  for  accurate 
examinations  and  records,  indispensable.  Eoughly  it  can  be  done  by  plac- 
ing the  patient  opposite  a  fixed  point  on  a  bare  black  or  dark  wall,  at  the 
distance  of  eight  inches.  "With  one  eye  covered  he  is  ordered  to  main- 
tain his  gaze  unswervingly  on  the  fixed  point.  A  small  white  object 
preferably  about  a  centimeter  in  diameter,  is  brought  into  the  field  from 
the  periphery  along  various  lines  radiating  from  the  fixed  point  and  the 
spot  marked"  at  which  it  is  first  perceived  by  the  patient.  By  joining  a 
series  of  such  points  the  outline  of  the  field  is  constructed  and  the 
various  color  limitations  are  similarly  defined  by  noting  the  distances  at 


64  NERVOUS  AND  MENTAL  DISEASES. 

which  the  color  of  the  test-object  is  clearly  recognized.  Large  blind 
spots  may  in  this  M^ay  sometimes  be  detected,  the  test-object  being 
carried  across  the  field  to  the  fixing-point.  The  normal  blind  spot  cor- 
responding to  the  optic  papilla  must  not  be  mistaken  for  a  symptom  of 
disease.  More  roughly  still  the  field  can  be  rapidly  tested  by  facing  the 
patient  at  a  distance  of  about  two  feet.  He  is  then  directed  to  look  you 
steadily  in  the  eye  opposite  the  one  to  be  tested ;  that  is,  if  the  patient's 
left  eye  is  under  examination,  he  looks  at  the  examiner's  right.  A  small 
object  is  brought  into  the  field  of  view  in  a  plane  midway  between  the 
patient  and  physician,  and  the  distance  at  which  it  is  recognized  is  noted. 
At  the  same  time  the  examiner's  own  perception  furnishes  a  check 
and  measure  to  the  test. 

The  subjects  of  Daltonism,  or  color-blindness,  are  congenitally  defective 
in  color  perceptions.  Some  have  complete  achromatopsia,  everything  to 
them  being  probably  of  a  neutral  tint ;  others  do  not  distinguish  some 
elementary  colors,  as  red  from  green  ;  and  others,  again,  fail  to  detect 
marked  shades  of  the  same  color.  This  defect  would  modify  tests  of 
color-fields  accordingly. 

Hearing. — The  sense  of  hearing  is  most  often  modified  by  local 
conditions  in  the  meatus  and  middle  ear.  Our  usual  problem  is  to  de- 
termine whether  the  nerve-apparatus  is  impaired.  To  this  end  we  note 
at  what  distance  on  either  side  the  patient  can  hear  a  watch,  remember- 
ing that  in  advanced  years  such  high-pitched  sounds  are  not  heard  so  read- 
ily as  lower  tones,  like  those  of  the  voice.  If  the  watch  is  not  heard 
through  the  air,  the  ear  should  be  closed  by  pressing  in  the  tragus  with 
the  finger  and  the  watch  brought  into  contact  with  the  root  of  the 
zygoma,  the  mastoid  process,  the  parietal  bone,  or  the  teeth.  If  it  is 
now  heard,  the  difficulty  is  presumably  in  the  conduction  apparatus,  and 
not  in  the  nerve.  This  can  be  confirmed  by  using  a  tuning-fork  in 
Rinne^s  test.  Set  it  in  vibration  and  place  the  handle  against  the 
mastoid  or  zygoma,  the  meatus  being  closed.  When  no  longer  heard, 
unstop  the  ear  and  hold  the  still  vibrating  fork  close  to  it.  The  nor- 
mal ear  will  detect  tones  through  the  air  that  do  not  reach  it  by  bone- 
conduction,  but  if  there  be  obstruction  in  the  external  or  middle  ear,  the 
bone-path  will  be  the  more  acute.  The  formula  is  B.  C.  >  A.  C.  or 
B.  C.=A.  C  If  there  is  no  recognition  of  high  or  low  tones  by  bone- 
conduction,  the  nerve-apparatus  is  undoubtedly  diseased,  or  if  with  hear- 
ing greatly  reduced  A.  C.  >  B.  C.  is  still  found,  the  probability  is  that 
the  nerve  is  diseased. 

Auditory  hyperesthesia  is  occasionally  encountered  in  acute  cerebral 
meningeal  conditions  and  in  hysteria.  Severe  headaches,  meningitis,  and 
many  cerebral  affections  are  marked  by  dysacousia, — sounds  producing 
discomfort, — which  may  or  may  not  be  attended  by  real  auditory  hyper- 
esthesia. In  the  relaxation  of  the  tensor  tyrapani  muscle  attending  facial 
palsy  low  notes  are  heard  with  unusual  distinctness,  while  those  of  high 
pitch  may  not  be  so  clearly  perceived  as  in  health. 

Subjective  sounds,  varying  from  an  insignificant  tinnitus  to  pronounced 
and  formulated  auditory  hallucinations  or  loud  explosions  in  the  head, 
are  referred  to  with  great  frequency  by  nervous  invalids.     Their  starting- 


THE  SPECIAL  SENSES.  65 

point  is  not  rarely  in  the  external  or  middle  ear.  Irritation  of  the  audi- 
tory centers  and  nerve,  however,  is  sometimes  the  cause. 

Involvement  of  the  labyrinth  or  of  its  nerves  is  marked  usually  by 
vertigo,  and  in  extreme  cases  by  forced  movements  in  a  given  direction, 
which,  as  in  Meniere's  disease,  may  furnish  attacks  of  great  sudden- 
ness, throwing  the  patient  to  the  ground.  The  space  sense  with  equili- 
bration is  disturbed. 

Finally,  in  no  case  of  obscure  brain  symptoms  should  the  possibility 
of  extension  of  infection  from  suppuration  in  the  middle  ear  and  mas- 
toid be  forgotten, — a  condition  that  specular  examination  and  local 
searcliing  should  reveal. 

Smell. — The  sense  of  smell  may  be  reduced  or  obliterated  in  one 
or  both  nostrils.  It  is  necessary  to  test  them  separately,  closing  firmly 
the  opposite  anterior  naris.  The  inspiratory  efforts  should  not  be  too 
vigorous,  as  thereby  the  test  odor  may  reach  both  nasal  spaces  through 
the  pharynx.  In  selecting  the  test-material,  pungent  odors  or  irritants, 
such  as  ammonia  or  tobacco-snuff,  should  not  be  employed.  In  hysteria 
anesthesia  of  the  mucosa  may  be  associated  with  absence  of  the  sense  of 
smell,  so  that  the  strongest  irritation  gives  rise  to  no  response ;  other- 
wise, when  the  olfactory  nerve  is  completely  destroyed,  stimulants  and 
irritants  have  their  usual  effect.  It  is  also  well  to  choose  an  odor 
with  which  the  patient  is  familiar,  and  to  recollect  that  people  vary 
greatly  in  keenness  .of  scent.  The  sense  of  smell  is  greatly  impaired 
by  nasal  catarrhal  trouble,  and  is  often  practically  lost  during  a  severe 
cold  in  the  head.  Degeneration  of  the  fifth  nerve,  which  supplies 
common  sensation  to  the  nasal  mucous  membrane,  also  lessens  its 
acuteness. 

Occasionally  the  sense  of  smell  is  greatly  intensified.  Hallucinations 
of  smell  are  rare,  and  in  several  cases  have  been  found  to  depend  upon 
disease  in  the  temporosphenoidal  lobe. 

Taste. — Pure  taste  sensations  are  the  recognition  of  bitter,  sweet, 
sour,  and  salt.  When  a  taste  is  associated  with  an  odor,  we  speak  of  a 
flavor,  and  it  requires  the  participation  of  the  olfactory  nerve,  usually 
stimulated  by  way  of  the  posterior  nares.  Flavors,  in  consequence,  are 
lost  with  the  loss  of  smell,  and  not  with  the  loss  of  taste.  The  margin 
and  tip  of  the  tongue  are  more  sensitive  to  sours  and  salts,  while  the 
base  and  pharyngeal  pillars  best  recognize  bitter  and  sweet.  The  en- 
tire gustatory  area,  which  includes  the  dorsum  of  the  epiglottis  and  even 
a  portion  of  the  rima  glottidis,  as  well  as  much  of  the  pharyngeal  wall, 
distinguishes  all  tastes  more  or  less  readily. 

For  the  purpose  of  testing  taste,  solutions  of  sugar,  quinin,  citric  acid, 
and  salt,  or  the  powdered  substances,  answer.  The  tongue  should  be 
protruded  and  the  test-substance  applied  to  a  small  area.  Some  moments 
are  usually  required  before  the  taste  is  perceived.  The  galvanic  electric 
current  furnishes  a  simple  and  reliable  agent.  Two  probe-pointed 
metallic  electrodes  a  few  millimeters  apart  are  placed  on  the  portion  of 
the  tongue  to  be  tested,  and  a  non-painful  current  from  one  or  two  cells, 
of  a  few  milliamperes'  volume,  is  used.      A  metallic  taste  is  elicited. 

Taste  is  lost  from  the  tip  of  the  tongue  in  lesions  of  the  facial  nerve 
5 


66 


NERVOUS  AND  MENTAL  DISEASES. 


involving  the  chorda  tympani,  and  from  the  rest  of  the  gustatory  area  in 
lesions  of  the  fifth  nerve  involving  its  lower  division  close  to  Gasser's 
ganglion.  Hemiplegic  states  rarely  show  a  one-sided  loss  of  taste,  while 
the  hemianesthesia  of  hysteria,  when  pronounced,  is  usually  marked  by 
ageusia  on  the  same  side. 

Perversions  of  taste — parageusia — and  increased  sensitiveness — 
hypergeusia — are  sometimes  encountered  in  neurotics  and  hysterics. 
Subjective  taste  sensations  are  also  rare,  but  may  furnish  the  aura  of  an 
epileptic  attack  or  be  dependent  upon  local  irritation  of  the  trunks  of  the 
nerves  of  taste,  as  in  ear  disease  affecting  the  chorda  and  facial  nerve. 


CHAPTER  VIII. 

SPEECH, 

There  are  as  many  kinds  of  speech  as  there  are  avenues  to  con- 
sciousness and  routes  therefrom.  We  have  spoken  language,  written 
and  printed  speech,  gestures  and  emotional  attitudes  that  portray  ideas 
and  serve  as  media  for  the  communication  of  ideas.  Consequently, 
speech  may  be  modified  by  disease  in  innumerable  ways  as  the  successive 
levels  of  the  nervous  system  are  invaded,  and  every  variety  of  speech 
may  be  disturbed  either  in  its  perceptive  or  emissive  channel. 

The  emission  of  vocal  speech  requires  mechanically  the  coordinate 
action  of  the  mouth  parts,  the  larynx,  and  the  chest-muscles  of  respira- 
tion. Malformations  of  the  nose,  throat,  mouth,  and  larynx  are  attended 
with  difficulty  in  shaping  the  resonant  chamber  for  the  precise  modifica- 
tions of  vocal  sounds  in  the  production  of  spoken  language.  Cleft-palate, 
closed  nasal  spaces,  and  tied-tongue  are  not  uncommon  conditions  of  this 
variety.  They  cause  difficulty  mainly  in  the  pronunciation  of  the  con- 
sonant sounds.  If  we  are  familiar  with  the  physiology  and  mechanism 
of  consonant  production,  we  have  the  key  to  diagnosis. 

For  this  purpose  the  accompanying  chart,  slightly  modified  from 


Physiological  Table  of  Consonants. 


Voiceless  Oral 
Consonants. 

Voiced   Oral 
Consonants. 

Voiced  Nasal 
Resonants. 

Labials 

P 

B 
W 

M 

Labiodentals      

F 

V 

Linguodentals 

Th 

S 

Th 
Z 

Anterior  linguopalatals 

Sh 
T 

Zh 
D 
L 
E 

N 

Posterior  linguopalatals 

K 
HorCh 

G 
Y 

Ng 

SPEECH.  67 

Wyllie,^  is  of  great  importance.  He  divides  consonants  into  voice- 
less and  vocal,  as  their  pronunciation  is  or  is  not  devoid  of  laryngeal 
sound.  By  having  the  patient  pronounce  these  letters,  or  phrases  con- 
taining them,  the  seat  of  the  difficulty  is  at  once  recognized.  For  in- 
stance, in  the  palatal  palsy  of  diphtheria  the  posterior  linguopalatals  and 
the  nasal  resonants,  especially  Ng,  which  depend  on  the  separation  of  the 
nasal  spaces  from  the  pharynx  by  the  soft  palate,  are  slurred  or  lost. 

Stammeringj  or  stuttering,  is  a  speech  defect  attended  by  difficulty 
in  attacking  properly  the  enunciation  of  words  beginning  with  certain 
consonants.  These  consonants  are  reiterated  with  more  or  less  spasmodic 
respiratory  effort,  and  finally  the  word  either  drops  out  or  is  explo- 
sively spoken.  There  is  always  more  or  less  incoordination  in  the 
needed  muscular  combinations. 

Speech  in  idiots  and  infants  often  consists  of  the  iteration  of  a  sylla- 
ble or  single  sound  (Jailing)  or  the  repetition  of  the  final  word  or  phrase 
overheard  by  them,  without  reference  to  its  meaning, — echolaUa.  In  mul- 
tiple sclerosis  the  speech  becomes  deliberate  and  each  syllable  is  pro- 
nounced with  the  distinctness  of  scanning.  In  general  paresis  the  words 
are  jumbled.  The  patient  catches  in  the  middle  of  words,  repeats  sylla- 
bles, slurs  sounds,  and  omits  terminals  or  even  important  words.  This 
is  called  syllable  stumbling.  In  hereditary  ataxia  the  speech  shows  the 
incoordinate  control  of  the  musculature  of  vocalization  and  is  usually 
slow,  monotonous,  and  unmodulated.  In  cerebral  palsies  with  athetosis 
speech  may  be  characteristically  modified  by  the  spasmodic  actions  of 
the  muscles  of  the  tongue,  throat,  and  chest.  It  is  explosive,  sputtering, 
now  slow,  now  fast,  and  the  tone  qualities  are  uncontrolled.  In  hysteria 
persistent  aphonia  is  a  frequent  symptom,  a  whispering  voice  only  re- 
maining. Complete  mutism  may  also  develop  slowly  or  suddenly  in  this 
malady,  but  voice  sounds,  as  in  coughing  or  sneezing,  usually  remain  to 
show  the  neurotic  character  of  the  disturbance.  In  progressive  bulbar 
pjalsy  the  paralysis  of  the  tongue  is  early  marked  by  indistinctness  of 
speech  and  a  loss  of  the  lingual  consonant  sounds.  If  the  lips  are 
weakened,  the  labials  can  not  be  produced,  and,  finally,  through  paralysis 
of  the  tongue  and  larynx,  vocal  speech  is  reduced  to  inarticulate  noises. 

In  diseases  marked  by  tremor,  as  in  alcoholism,  Graves'  disease,  and 
paralysis  agitans,  the  voice  is  also  tremulous.  Depression,  excitement, 
and  the  emotions  generally  are  manifest  in  the  timbre  and  modulation  of 
the  voice.  The  deaf  are  inclined  to  speak  in  a  monotonous,  high,  or 
more  often  low,  tone  that  is  quite  peculiar  to  them. 

Aphasia. — Organic  disease  of  the  brain,  throwing  out  of  operation 
the  various  cortical  centers  related  to  speech  or  breaking  up  their  con- 
necting channels,  produces  peculiarly  interesting  phenomena  that  require 
very  careful  examination.  Any  of  the  qualities  or  varieties  of  speech 
may  be  affected,  or  almost  any  combination  of  defects  may  be  present  in 
a  given  case.  Practically  we  have  to  investigate  both  spoken  and  written 
speech  and  to  determine  first  how  they  are  received  and  apprehended, 
and,  second,  how  conceived  and  expressed.      In  other  words,  we  try  to 

1  "  Disorders  of  Speech,"  Edinburgh,  1894. 


68  NERVOUS  AND  3IENTAL  DISEASES. 

determine  whether  the  difficulty  lies  in  the  entrance-channel  or  the 
receptive  center  on  the  one  hand,  or  in  the  formulating  center  and  the 
emissive  route  on  the  other. 

Take,  first,  the  reception  of  spoken  speech.  Is  the  hearing  good,  tested 
by  watch,  tuning-fork,  voice,  and  various  sounds?  If  so,  does  the 
patient  understand  the  words  used  ;  or  is  he  word-deaf — that  is,  while 
hearing  words  does  he  fail  to  appreciate  their  meaning  ?  Test  this  by 
directing  him  to  execute  certain  movements — to  shut  his  eyes,  clap  his 
hands,  etc. 

Second,  how  does  he  produce  spoken  speech  f  Is  it  reduced  to  a 
single  expletive  or  phrase,  or  is  he  completely  dumb  ?  Does  he  forget 
names  of  common  objects  (amnesia  verbalis),  stammer,  slur,  stumble,  or 
reiterate  ?  Does  he  miscall  objects  with  which  he  is  familiar  (paraphra- 
sia),  and  is  he  aware  of  his  mistakes  ?  Is  his  speech  a  jargon  of  mean- 
ingless sounds  or  words  strung  together  like  beads  ?  If  dumb,  can  he 
write  his  answers  ?  and  if  he  can  not  write,  can  he  indicate  with  his 
fingers  the  number  of  syllables  in  the  names  of  objects  pointed  out  to 
him  ?  Finally,  can  he  repeat  or  echo  what  is  said  to  him,  or  is  he 
inclined  to  echo  his  own  words  or  expressions?  does  he  understand 
his  repeated  words? 

Written  Speech. — If  vision  is  good,  does  the  patient  understand 
written  or  printed  questions  ?  This  can  best  be  determined  by  writing 
simple  commands,  as,  stand  up  !  sit  down  !  give  me  your  hand  !  and 
not  by  questions  that  can  be  answered  by  a  nod.  Proper  responses 
show  comprehension.  If  the  written  questions  or  commands  are  only 
partially  understood,  we  must  attempt,  by  repeated  tests,  to  decipher  the 
limitations  of  his  alexia.  Secondly,  does  he  write  ?  If  agraphia  is  not 
present,  does  he  use  wrong  nouns  {paragraphia),  repeat  letters  or  words, 
or  make  serious  omissions  ?  Can  he  write  from  dictation  and  from 
copy,  and  does  he  then  understand  what  he  thus  writes  ? 

When  other  speech  avenues  of  the  mind  are  blocked  or  only  partly 
obstructed,  the  recognition  of  gestures,  their  use  and  repetition,  should 
be  noted.  Some  patients  do  not  recognize  gestures  (amimia),  or  employ 
wrong  gestures  in  attempting  to  explain  themselves  [paramimia). 

To  some  patients  objects  have  lost  their  meaning,  so  that  familiar 
things  and  intimate  friends  are  not  recognized, — a  condition  called  mind- 
blindness.  The  sense  of  touch  (stereognosis)  may  stiil  furnish  informa- 
tion to  the  mind  that  has  lost  its  recognition  of  visual  impressions,  so 
that  a  piece  of  money  or  familiar  object  unrecognized  by  sight  may 
be  correctly  named  when  placed  in  the  hand,  though  this  faculty  is 
also  commonly  defective  when  there  is  mind-blindness. 

The  handwriting,  especially  with  the  pen,  in  many  cases  furnishes 
diagnostic  evidence  of  great  value,  as  well  as  a  means  of  studying  the 
progress  of  the  disease.  A  hand-magnifier  will  often  bring  out  peculi- 
arities that  are  not  readily  seen  by  unaided  vision,  and  for  the  same 
purpose  photographic  enlargement  may  be  used.  When  abnormalities 
are  slight  or  only  suspected,  a  specimen  from  something  written  several 
months  or  years  previously  will  serve  as  a  proper  basis  for  comparison. 
Appropriate  allowances  for  youthful  growth  or  the  decrepitude  of  age 


SPEECH.  69 

must  be  made.  The  education,  habitude  of  writing,  and  physical  con- 
dition at  the  time  are  also  to  be  considered.  As  a  rule,  in  health  the 
down  strokes  are  made  with  more  strength,  precision,  and  rapidity  than 
the  other  written  lines.  If  they  show  inequalities,  tremor,  waves,  or 
marked  angularities,  the  significance  is  greater  than  the  appearance  of 
these  anomalies  in  the  upward  lines  or  connecting  curves.  The  signing 
of  the  patient's  name,  for  those  who  write  it  frequently,  becomes  quite 
automatic,  and  often  fails  to  fairly  show  the  character  of  the  disturb- 
ance. It  is  well  to  dictate  some  ordinary  sentence,  to  have  the  patient 
copy  a  paragraph  from  a  newspaper,  or  write  a  little  account  of  his  ill- 
ness. Many  times  it  is  only  after  writing  a  few  minutes  that  the  diffi- 
culty manifests  itself.  This  is  particularly  true  in  writers'  cramp.  In 
general  paresis  the  first  of  a  letter  page  may  be  well,  firmly,  and  co- 
herently written,  the  latter  part  showing  tremor,  inequalities,  omitted 
words,  and  incoherence.  Blots,  spatters,  and  wavering  lines  demonstrate 
the  ataxia  of  the  patient.  The  aphasic  shows  his  cerebral  lacunse  by 
using  wrong  words,  by  writing  jargon,  and  by  the  repetition  of  letters, 
syllables,  and  words  or  phrases  when  not  intended. 

Jlirroi'-ivriting  is  a  variety  in  which  the  letters  are  formed  back- 
ward, like  printers'  type,  and  appear  properly  when  viewed  in  a  re- 
flecting surface.  Left-handed  children  often  write  thus  naturally,  and 
it  has  been  noticed  in  hysterics  and  degenerates.  Rare  cases  of  mirror- 
speech  have  been  recorded,  in  which  words  were  inverted  by  syllables  or 
literally. 

Varieties  of  handwriting  are  given  in  the  description  of  the  various 
diseases  which  present  such  peculiarities. 


Finally,  photography  furnishes  a  most  valuable  adjunct  to  case-taking 
when  any  peculiarity  of  conformation,  attitude,  gait,  or  facial  expression 
is  observed.  Serial  photographs  vividly  present  the  course  of  the  dis- 
ease. The  use  of  a  case-book,  properly  prepared,  is  of  the  utmost  value 
to  systematize  the  examination  and  secure  a  full  but  concise  record. 
The  form  given  on  page  70  may  serve  as  an  outline,  requiring  to  be 
properly  spaced  for  actual  use. 


70 


NERVOUS  AND  3IENTAL  DISEASES. 


FoEM  FOR  Neurological  Case-book  Page. 

JS^ame Nationality Date 

Residence Age Civil  Condition Children 

Occupation Heredity 

Health  History  


Injuries  

Habits 

Present  Illness . 


PRESENT  CONDITION. 


Alimentary  System 

Eyes 

Circidatory  System 

Respiratory  System 

Lids 

Tegumentary  System 

Pupils 

Genito-urinary  System 

Movements 

Pulse            Temperature         Weiglit 

Vision 

General  Appearance 

Field 

Attitxide 

Fundus 

Gait 

Ears      ■ 

Motor  Condition 

Deformities 

Hearing 

Sense  of  Smell 

Sphincters 

Mouth 

Lips 

Sensory  Conditions 

Tongue 
Palate 

Articulation 

Subjective 

Voice 

Objective 

Aphasia 

Muscular 

Deglutition 

Delayed 

Taste 

Thermic 

Diminished 

Brain 

Intensified 

Pain 

3Iemory 

Logical  Potvers 

Emotions 

Electric  Conditions 

Consciousness 

Vertigo 

Sleep 

Spinal  Cord 

Trophic  Conditions 

Superior  Reflexes 

Deep  Reflexes 

- 

Coordination 

Diagnosis 

Spinal  Column 

Treatment 

Handwriting 

PAET   II. 

DISEASES  OF  THE  CEREBRAL  MENINGES  AND 
CRANIAL  NERVES. 


CHAPTER  I. 


THE  CEREBRAL  MENINGES— PACHYMENINGITIS  AND 
PIAL  HEMORRHAGE. 

Anatomical  Considerations. — The  coverings  of  the  brain  are 
admirably  suited  to  protect  it  from  injury  and  infection.  Guarded  ex- 
ternally by  the  skull  and  the  scalp-pad,  it  is  intimately  enveloped  by  the 
dense,  fibrous  dura  mater  in  a  practically  sealed  sac.  The  usual  anatom- 
ical descriptions  of  the  cerebral  meninges  are  misleading.  Ordinarily 
three  distinct  membranes  are  named  and  described,  when  in  reality  there 
are  but  two.  Lining  the  skull  we  have  the  dura  mater,  serving  as  an 
internal  periosteum  for  the  cranial  bones  and  furnishing  in  ])art  their 
vascular  supply.  It  is  entirely  free  from  the  brain,  but  gives  off  sheaths 
to  the  cranial  nerves  and  the  large  vessels  at  their  exit  from  the  skull, 
and  supplies  venous  channels  or  sinuses  for  the  return  circulation  of  the 
encephalon.  The  dural  fold  between  the  cerebral  hemispheres  and  the 
tentorium  cerebelli  afford  support  and  protection. 

In  normal  conditions  the  brain  fills  the  cranial  cavity  fully,  and  its 
soft  covering  membrane  is  everywhere  in  contact  with  the  inner  surface 
of  the  dura.  The  interval  which  separates  them  is  called  the  subdural 
space.  No  actual  space,  however,  exists,  the  two  membranes  being 
smoothly  applied  to  each  other  and  only  separated  by  disease  or  mechan- 
ical means. 

Closely  investing  the  brain  is  the  jikt  mater,  made  up  of  two  layers 
or  membranes  very  loosely  attaclied  by  delicate  meshes  of  fibrous  tissue. 
The  outer  can  be  easily  stripped  from  the  under  layer,  and  constitutes 
what  is  usually  described  as  the  arachnoid.  The  alleged  double  layers 
and  spaces  of  the  so-called  arachnoid  can  not  be  demonstrated  and  do 
not  exist.  This  outer  pial  layer  we  may  call  the  arachnopia.  Between 
it  and  the  under  layer,  or  visceral pia,  is  a  varying  space,  the  p>kd  space, 
filled  with  a  delicate,  open,  reticular  network  of  fibrous  tissue  containing 
cerebrospinal  fluid  or  lymph.  It  is  an  enormous  lymph-space.  At  the 
gyral  grooves  the  visceral  pia  dips  to  the  bottom  of  the  sulci.  It 
everywhere    closely    adheres    to    the    brain-cortex,    which    it    follows 

71 


72 


DISEASES  OF  THE  CEREBRAL  MENINGES. 


through  the  transverse  fissure  into  the  ventricular  chambers,  furnishing  the 
velum  interpositum  and  bearing  the  choroid  plexuses.  The  arachnopia 
bridges  over  the  sulci.  This  arrangement  at  the  great  fissures  and  at 
the  base  of  the  brain  in  the  intervals  between  the  cerebrum,  cerebellum, 
and  medulla  forms  lymph-reservoirs,  which  are  continuous  with  the  pial 
spaces  of  the  spinal  cord  through  the  foramen  magnum.  Delicate  proc- 
esses of  the  pia  also  accompany  the  cranial  nerves  and  vessels  from  the 
skull,  and  are  continuous  with  the  extracranial  lymph-channels. 

Between  the  pial  layers  the  cerebral  vessels  ramify.     As  they  pene- 


Fig.  25.— Diagram  of  cerebral  meninges  and  cortex.  V,  darn  mater;  S.  I).,  subdural  space;  P.  S.,  pial 
space;  A.  P.,  arachnopia;  V.  P.,  visceral  pia;  JC,  arterial  perivascular  space;  Z,  venous  perivascular 
space  (Tuke). 

trate  the  cortex  both  arteries  and  veins  are  accompanied  by  deli- 
cate sheaths  of  the  visceral  pia,  which  form  the  perivascular  lymph- 
spaces  of  the  brain.  Some  of  the  great  pyramidal  cells  of  the  cortex 
are  encapsuled  by  diverticula  from  these  perivascular  lymph-channels, 
and  are  thus  nourished.  In  a  manner,  therefore,  these  most  important 
cortical  elements  may  be  considered  as  appendages  of  the  pia,  with 
which  they  have  such  intimate  anatomical  relations.  The  pia  also 
pushes  up  the  Pacchionian  bodies  into  the  vascular  area  of  the  dura 
near  the  venous  sinuses  at  the  vertex.  These  bodies  are  supposed  to- 
furnish  an  outlet  for  the  meningeal  lymph. 


PACHYMENINGITIS.  73 

The  brain  is  constantly  changing  in  bnlk  through  variations  in  vascu- 
larity due  to  mental  or  physical  activity.  This  would  be  impossible 
were  it  not  for  the  ready  displacement  of  the  cerebral  fluid.  Losses  of 
brain-substance  by  atrophy  or  otherwise  are  mechanically  compensated 
in  bulk  by  an  increase  in  the  pial  Huid  and  the  hydrostatic  balance  is 
preserved.  The  wide  ramifications  of  the  pial  structure  through  the 
substance  of  the  brain,  its  lymphatic  prolongations,  and  its  ventricular 
relations  make  plain  many  of  the  symptoms  of  meningitis  and  account 
for  the  serious  sequels  of  the  disease. 


INFLAMMATION  OF  THE  DURA  MATER— PACHYMENINGITIS. 

The  dura  mater,  though  a  tough,  resisting,  fibrous  structure,  is  subject 
to  inflammatory  invasion.  As  the  outer  or  inner  surface  is  affected,  we 
speak  of  pachymeningitis  externa  and  pachymeningitis  interna. 

Pachymeningitis  externa  is  not  a  clinical  unit.  "When  the  outer 
surface  of  the  dura  becomes  inflamed,  it  is  always  a  secondary  condition, 
the  result  of  the  extension  to  it  of  infection  from  adjoining  structures. 
Fractures  of  the  cranium  attended  by  sepsis,  osteitis,  necrosis,  and  new 
growths  in  the  cranial  bones  may  be  its  starting-point.  Suppuration 
of  the  middle  ear  sometimes  propagates  inflammation  to  the  dural  cov- 
ering of  the  temporal  bone.  A  cranial  gumma  may  incite  it.  Usually 
it  is  limited  in  extent.  Very  rarely  considerable  accumulations  of 
purulent  material  between  the  dura  and  the  skull  may  strip  the  mem- 
brane from  the  bone  and  occasion  cerebral  disturbance  by  localized 
pressure. 

The  dura  becomes  thickened  and  forms  strong  adhesions  to  the  inner 
surface  of  the  cranial  bones.  The  danger  consists  in  a  resulting  sinus- 
thrombosis  or  in  septicemia.  The  treatment  is  that  of  the  surgical  con- 
dition of  which  the  pachymeningitis  is  the  sequel. 

Pachymeningitis  interna,  pachymeningitis  hcBmorrhagica,  or  hema- 
toma of  the  dura  mater,  is  a  chronic  inflammation  of  the  inner  surface 
of  the  dura  mater  marked  by  one  or  more  hemorrhagic  membranous 
layers. 

Etiolog-y. — The  arterial  changes  resulting  from  alcoholism  are  fre- 
quently the  cause  of  this  condition.  In  undoubted  instances  the 
congestion  following  alcoholic  abuse  has  determined  the  vascular 
rupture  that  furnishes  the  laminated  membranes.  In  dements,  and 
especially  in  paretic  dements,  it  is  a  common  post-mortem  finding.  In- 
fectious maladies,  the  exanthemata,  erysipelas,  and  cachectic  states, 
especially  those  marked  by  purpuric  conditions,  as  scurvy,  sometimes 
lead  to  it.  It  is  more  frequent  among  men  than  among  women,  and 
appears,  as  a  rule,  early  or  late  in  life. 

Patholog-ical  Anatomy. — Internal  pachymeningitis  is  essentially 
characterized  by  the  thickening  of  the  dura  and  the  deposition  inter- 
nally of  laminated  new  membranes  of  hemorrhagic  origin.  ^  Rasweden- 
kow  2  insists  that  the  first  change  is  proliferation  of  the  epithelial  layer 

1  Meyer,  "Path.  Report,  111.  Eastern  Hosp.  for  Insane,"  1896. 
^  "  Ziegler's  Beitrag.,"  Bd.  xxvii. 


74 


DISEASES  OF  THE  CEREBRAL  MENINGES. 


followed  by  fibriuous  exudation  and  the  formation  of  thin-walled  capil- 
laries and  that  the  primary  condition  is  a  toxemia.  Barratt  ^  thinks  that 
intravascular  separation  of  fibrin  is  a  constant  initial  feature  followed  by 
the  other  changes  and  finds  such  resulting  membranes  free  from  bacteria. 
These  layers  vaiy  in  number  from  two  or  three  to  as  many  as  twenty,  and 
in  consistency  from  that  of  freshly  extravasated  blood  to  tough,  well- 
organized,  leathery  membranes.  They  present,  according  to  their  age, 
the  colors  of  blood  under  similar  circumstances  elsewhere.  The  new 
ones  are  bright  red,  the  older  ones  yellow.  They  are  only  slightly  adhe- 
rent to  the  dura  and  to  one  another  by  fibrous  connections,  and  are  quite 
vascular  when  of  some  age.  Their  blood-vessels  are  delicate,  poorly 
developed,  and  readily  degenerate,  thus  furnishing  new  hemorrhages, 
which  separate  the  older  layers  or  form  new  ones  on  the  cerebral  sur- 
face. Adhesions  to  the  arachno- 
pia  are  practically  wanting.  The 
cerebral  convolutions  are  flat- 
tened if  the  stratified  new  forma- 
tion attains  considerable  propor- 
tions, and  the  cranial  bones  may 
also  present  pressure  atrophy. 
In  children  the  ossification  of 
sutures  and  fontanels  is  retarded. 
This  form  of  dural  disease  is 
usually  found  at  the  vertex,  in 
the  distribution  of  the  middle 
meningeal  arteries  over  the  motor 
zone,  but  occasionally  the  basal 
fossae  are  involved. 

Symptoms. — The  symptoms 
of  the  early  stage  before  hemor- 
rhages have  occurred,  and  when 
the  process  is  purely  inflamma- 
tory, are  very  vague.  In  many 
cases  no  suspicion  of  the  disease 
has  been  raised  during  life.  The  first  recognizable  symptoms  attend 
the  formation  of  a  hematoma  large  enough  to  produce  cerebral  indica- 
tions. These  consist  of  pain  in  the  head,  intellectual  troubles,  loss  of 
memory,  awkwardness  in  muscular  movements,  insomnia,  vertigo, 
rarely  vomiting,  limited  or  Jacksonian  convulsions,  apoplectiform  attacks, 
rigidities  and  monoplegias  presenting  remissions.  The  temperature  is 
fickle  and  uninstructive.  During  the  convulsive  attacks  it  attains  a 
high  degree,  but  in  the  intervals  may  be  subnormal,  normal,  or  slightly 
elevated. 

Course. — As  the  early  symptoms  escape  recognition,  the  duration 
of  the  disease  is  indeterminate.  It  usually  runs  a  protracted  course, 
and  may  in  rare  instances  terminate  in  recovery,  with  resorption  of  most 
of  the  new  tissue.  As  it  is  practically  an  expression  of  a  serious  or 
hopeless  underlying  condition,  the  ordinary  end  is  death.     This  may 

1  "Brain,"  1902. 


Fig.  26. — Pachymeningitis  interna  in  a  rachitic 
child  with  scurvy.  The  ditFerent  layers,  with  cotton- 
wool pledgets  interposed,  are  seen  on  the  right  side  of 
the  skull  anteriorly  (Southerland). 


PIAL  HEMOBBHAGE.  75 

follow  an  apoplectiform  seizure  or  a  comatose  condition,  but  usually  is 
preceded  at  intervals  by  a  number  of  such  attacks,  each  of  Avhich  leaves 
a  certain  trace  behind  it  in  the  form  of  added  mental  or  motor  dis- 
ability. 

Diagnosis. — The  diagnosis  is  difficult.  In  drunkards,  dements, 
and  cachectic  children  the  appearance  of  the  cerebral  symptoms  men- 
tioned should  call  the  disease  to  mind.  A  history  of  preceding  convul- 
sive attacks,  with  practically  complete  remissions,  would  strengthen  the 
suspicion.  It  forms  anatomically  a  subdural  tumor,  and  at  times  pre- 
sents all  the  symptoms  of  a  new  growth  in  that  locality.  The  noc- 
turnal cephalalgia  of  syphilitic  meningeal  involvement  and  other  luetic 
features  will  usually  differentiate  that  disease.  The  distinction  from 
tubercular  meningitis  in  children  rests  upon  the  absence  of  constipation, 
abdominal  retraction,  severe  headache,  rigidity  of  the  neck,  and  intense 
respiratory  and  circulatory  troubles.  In  the  aged,  cerebral  apoplexy 
usually  is  of  more  rapid  onset,  but  cerebral  thrombotic  softening  often 
presents  a  parallel  symptom  group. 

Treatment  consists  of  measures  to  relieve  the  basic  condition.  Alco- 
holic addiction,  infectious  diseases,  and  the  cachexise  having  received 
appropriate  attention,  the  various  cerebral  indications  are  met  as  they 
arise.  Quiet,  the  ice-cap,  elevation  of  the  head,  antispasmodics,  cathar- 
tics, sinapisms,  hot  foot-baths,  and  other  means  to  decongest  the  cerebral 
circulation  will  be  of  service  during  the  convulsive  attacks.  Ergot 
should  not  be  advised,  as  the  bleeding  vessels,  devoid  of  muscular 
layers,  would  be  placed  at  a  still  furtlier  disadvantage  by  the  increased 
arterial  tension.  Monro  and  Ballard,  of  Boston,  have  reported  a  number 
of  cases  in  adult  alcoholics  successfully  treated  by  trephining  and  the 
evacuation  of  the  clots.  When  the  diagnosis  can  be  made,  such  pro- 
cedure is  urgently  indicated. 

PIAL  HEMORRHAGE. 

Pial  hemorrhage,  or  meningeaL  hemorrhage,  takes  place  either 
outside  of  the  arachnopia,  on  the  inner  surface  of  the  dura,  or  within 
the  meshes  of  the  pia,  or  in  both  locations  at  once.  The  extrapial 
variety  of  meningeal  hemorrhage  may  be  found  at  all  ages,  but  is  most 
common  in  the  new-born.  In  about  one-half  of  the  cases  still-born 
children  present  this  accident,  apparently  due  to  protracted  labor,  some- 
times to  instrumental  delivery,  and  even  to  precipitate  birth.  In  one- 
third  of  the  cases  of  asphyxiated  new-born,  Cruveilhier  claims  that 
subdural  hemorrhage  is  the  main  difficulty.  The  clots  are  commonly 
found  over  the  convexity,  and  are,  in  surviving  cases,  a  pregnant  source 
of  idiocy  and  cerebral  palsy. 

Later  in  life  pial  hemorrhage  is  usually  produced  only  by  extreme 
violence  to  the  skull,  as  in  concussing  injuries  or  fractures.  The  hem- 
orrhage may  come  from  a  dural  sinus  or  from  the  meningeal  arteries. 
It  practically  requires  a  fracture  with  displacement  or  a  penetrating 
wound  to  cause  sinus  bleeding.  The  location  of  the  middle  meningeal 
artery  in  a  bony  channel  at  the  anterior  inferior  angle  of  the  parietal 


76  DISEASES  OF  THE  CEREBRAL  MENINGES. 

bone,  a  frequent  seat  of  fractures  and  direct  violence,  renders  it  particu- 
larly liable  to  injury.  In  many  cases  the  hemorrhage  from  the  meningeal 
vessels  takes  place  at  the  contre  coup  point.  Certain  debilitating  and 
infectious  conditions  predispose  to  and  may  rarely  cause  subdural  hem- 
orrhage ;  for  instance,  hemophilia,  purpura,  small-pox,  scarlatina, 
typhus,  typhoid,  and  acute  rheumatism.  It  is  found  in  chronic  alco- 
holism, especially  after  a  debauch.  A  ruptured  meningeal  aneurysm 
may  flood  the  subdural  space. 

The  onset  is  acute  and  marked  by  apoplectic  seizure  and  rapidly 
developing  unconsciousness.  In  traumatic  cases  the  patient  not  seldom 
rallies  more  or  less  from  the  first  bewilderment  of  the  concussion,  and 
after  a  variable  interval  of  minutes,  or  even  hours,  sinks  into  uncon- 
sciousness. The  cortical  irritation  is  manifest  in  one-sided  or  more  cir- 
cumscribed and  repeated  convulsions,  rigidities,  and  tremors.  The 
pupils  dilate  unevenly,  the  coma  becomes  profound,  the  pressure  indi- 
cations intensified,  and  the  patient  usually  dies  in  from  twenty-four  to 
seventy- two  hours,  unless  relieved  by  operation. 

Intrapial  hemorrhage  takes  place  within  the  pial  spaces,  or  strips  the 
pia  from  the  cerebral  cortex.  It  is  the  usual  meningeal  hemorrhage  of 
adult  life,  and  its  common  location  is  toward  or  in  the  basal  region. 

The  extravasated  blood  may  widely  infiltrate  the  pial  spaces  or 
merely  form  diffuse  ecchymotic  discolorations.  In  large  quantities  it 
may  force  itself  into  the  ventricles  through  the  transverse  fissure,  and 
even  travel  down  into  the  pial  spaces  of  the  cord.  Usually  it  forms  a 
thin  covering  over  the  surface  of  the  convolutions,  dipping  into  and  fill- 
ing the  intervening  sulci.  Under  the  hemorrhage  the  surface  of  the 
cortex  often  appears  softened  and  lacerated.  Ordinarily  the  blood  is  of 
arterial  origin  ;  rarely  it  comes  from  veins  and  very  exceptionally  from 
a  ruptured  sinus.  Except  in  traumatic  cases,  disease  of  the  vessels, 
such  as  aneurysm,  miliary  aneurysm,  sclerosis,  atheroma,  fatty  degenera- 
tion, or  acute  infectious  softening  of  their  walls,  furnishes  the  essential 
element  of  causation.  It  follows  that  periarteritis  and  endarteritis  are 
the  initial  steps  in  the  process  that  eventuates  in  hemorrhage.  The  de- 
velopment of  these  conditions  is  taken  up  more  at  length  under  the 
diseases  of  cerebral  arteries  in  Part  III,  to  which  the  reader  is  referred. 

The  onset  of  this  form  of  meningeal  hemorrhage  is  also  acute  and 
apoplectic,  with  a  rapid  downward  tendency  toward  death.  There 
may  be  partial  temporary  restoration  to  consciousness,  but  the  patient 
presents  indications  of  great  shock  and  feebleness.  A  recurrence  of 
apoplectic  symptoms  is  usually  quickly  followed  by  death.  Previous  in- 
dications of  localized  disease,  such  as  aneurysm  of  the  basilar  or  other 
large  vessel  of  the  base,  may  have  been  present  in  the  form  of  cranial- 
nerve  palsies  with  the  usual  features  of  endocranial  tumors.  The  apo- 
plectic seizure  is  usually  less  sudden  and  violent  than  in  cerebral  hem- 
orrhage of  the  ordinary  capsular  variety,  and  often  rather  gradually 
develops  the  full  apoplectic  state  and  profound  coma.  Hemiplegia  and 
conjugate  deviation  of  the  head  and  eyes  have  been  noted  in  rare  cases, 
but  their  absence  is  the  rule,  and  aids  in  diiferentiating  this  condition 
from    cerebral    hemorrhage.     Epileptiform    and    tetanic    features    are 


JNFLAM3IAriON  OF  THE  PI  A  MATEB.  77 

occasionally  present  and  ini])ly  cortical  irritation.  The  pulse  may  be 
slow  and  respiratory  difficulty  present.  At  first  the  rectal  tempera- 
ture is  reduced,  but  returns  to  the  normal  and  rapidly  mounts  as  death 
approaches.  This  takes  place,  as  a  rule,  in  from  a  few  hours  to  a  few 
days.     Rare  cases  have  endured  a  week,  and  still  rarer  ones  survived. 

The  diagnosis  of  intrapial  hemorrhage  is  difficult.  It  closely  resem- 
bles cerebral  hemorrhage,  cerebral  thrombosis,  and  the  hemorrhage  arising 
from  pachymeningitis  interna.  The  chief  symptoms  on  which  reliance 
is  to  be  placed  are  the  rapidity  of  onset  and  the  quickly  increasing  symp- 
toms without  paralysis  and  convulsions.  An  internal  pachymeningitis 
usually  presents  a  significant  history  of  headaches,  and  occurs  in  a  lim- 
ited class  of  patients  with  gross  degenerations.  The  differential  features 
of  cerebral  hemorrhage  and  softening  are  tabulated  in  Part  III. 

The  outlook  is  extremely  grave  and  death  is  almost  certain  to  ter- 
minate the  case.  In  these  days  of  aseptic  cranial  surgery  an  exploratory 
opening  is  allowable,  and  furnishes  practically  the  sole  means  of  con- 
trolling the  hemorrhage  and  saving  the  patient. 


CHAPTER  II. 
INFLAMMATION  OF  THE  PIA  MATER. 

Leptomeningitis,  acute  cerebral  meningitis,  cerebrospinal  meningitis, 
purulent  meningitis,  inflammation  of  the  soft  cerebral  coverings,  is  an 
acute,  sometimes  epidemic  disease  of  a  heteroinfectious  character,  con- 
sisting of  inflammation  of  the  pia  mater  and  marked  by  an  irregular 
clinical  course. 

It  is  not  uncommon  in  systematic  works  to  divide  leptomeningitis 
into  numerous  varieties,  such  as  simple,  serous,  purulent,  primary,  sec- 
ondary, idiopathic,  epidemic,  tubercular,  basilar,  etc.  From  an  etiological 
and  anatomical  standpoint  this  is  not  required,  but  epidemic  cerebrospinal 
meningitis  will,  in  the  general  description,  receive  such  special  remark 
as  seems  required.  Tubercular  meningitis,  however,  is  clinically,  etio- 
logically,  and  anatomically  a  distinct  disease,  and  will  be  accorded  a 
separate  section. 

Etiology. — The  pial  structures  can  be  invaded  in  but  two  ways  :  by 
traumatic  or  destructive  lesions  of  the  bony  and  fibrous  envelopes  of  the 
brain  on  the  one  hand,  or  through  the  vascular  supply  on  the  other.  To 
the  first  group  belong  those  cases  of  meningitis  arising  from  direct  in- 
oculation, as  in  cranial  fracture  and  septic  extension  from  neighboring 
foci  in  the  scalp,  face,  cranial  bones,  the  middle  ear,  the  mastoid  cells, 
the  nasal  fossae,  antra,  and  sinuses,  and  from  the  orbit  and  pharynx. 
To  the  second  group  belong  the  larger  number,  which,  formerly  called 
idiopathic,    are   now   known   to   depend   on    microbic    infection.     The 


78  DISEASES  OF  THE  CEREBRAL  MENINGES. 

exact  infection  path  is  often  problematical.  Ortman  pointed  out  the 
presence  of  coryza  in  a  large  proportion  of  the  cases,  and  supposed  that 
the  infection  reached  the  pial  space  through  the  lymph-channels  of 
the  nasal  vault,  which  are  continuous  with  those  of  the  brain. 

In  the  epidemic  form  Scherer  ^  again  calls  attention  to  the  severe 
nasal  catarrh  at  the  commencement  of  the  attack.  Weigerts  in  eighteen 
cases  found  purulent  nasal  catarrh,  and  demonstrated  Weichselbaum's 
diplococcus  intracellularis  meningitidis  in  the  secretions.  In  fifty  per- 
sons not  sufFering  from  the  disease  he  found  this  diplococcus  in  two  in- 
stances and  supposes  that  it  is  inhaled,  taken  up  by  the  leukocytes,  and 
by  them  carried  into  the  lymph-spaces  of  the  brain  through  the  nasal 
vault.  Flexner  and  Barker  2  emphasize  the  probability  of  the  infection 
atrium  being  in  the  intestinal  tract.  The  close  relation  of  pneumonia 
to  meningitis  has  for  a  long  time  pointed  to  the  lungs  as  an  invasion 
route.  As  a  clinical  fact,  any  infection  at  any  near  or  remote  point 
may  induce  meningeal  inflammation  by  way  of  the  vascular  system. 

Bacteriologically,  a  case  of  acute  meningitis  may  present  one  or  many 
organisms.  Those  most  frequently  found  alone  are  Weichselbaum's 
diplococcus,  the  pneumococcus,  the  streptococcus,  the  typhoid  bacillus,^ 
and  the  bacillus  coli.  In  association  with  them,  and  perhaps  often  as  a 
secondary  infection,  are  found  the  staphylococcus  aureus  and  albus  and 
various  indeterminate  streptococci  and  bacilli.  The  most  common  of  all 
and  the  most  significant  are  the  pneumococcus  and  the  diplococcus  intra- 
cellularis. These  microorganisms  are  found  in  the  meningeal  fluid,  but 
may,  as  in  a  general  pneumococcic  infection,  be  widely  distributed 
throughout  the  body.  Lately  the  diplococcus  of  Weichselbaum  has 
been  demonstrated  in  the  pus  of  arthritis,  occurring  in  a  case  of  menin- 
gitis, and  also  in  the  blood. ^  Osier,  in  the  Cavendish  lectures  for  1899, 
made  the  following  practical  classification  : 

1.  Of   cerebrospiual    f   (a)  Sporadic.  "I    Diplococcus    intracellu- 

fever.  1    (6)  Epidemic.  J        larls. 

I  2.  Pneumococcic.        \   -^leni.iges  alone  involved  or  in  a  general    1    pneumococcus. 
^.  i..  J.  uouii.v/v,uv,^iv.         -j^       pneumococcus  infection.  j 

1.  Tuberculous Bacillus  tuberculosis. 

{(a)  Secondary  to  pneumonia,  endocardi-  ~] 
tis,  etc.  .J.  ■   .  r    y  Pnenmococcus. 

{b)  Secondary   to  disease  or   injury   of 
cranium  or  its  fossa.  J 

I    (a)  Following  local  disease  of  cranium  -l    various    forms    of   sta- 

3.  Pyogenic.  j        or  a  local  infection  elsewhere.  I        phviococci  and  strep- 
■' ^                          I    (6)  Terminal    infection    m   various  f       fococci 

L      eliroiiic  maladies.  J 

r  T     i     1    •  1  ^  -a  J-   i,ii,     ■      1    Typhoid  hacillns,  influ- 

4.  Miscellaneous         J    ^"  ^■^P'^^'^  fever  influenza  diphtheria,  ^V        bacillus,    diph- 

acute  infections.  |      frottcrdiSses"""""^^^^'^'  /      ^ jf^,  ^etc^"'"^'  ^^^ 

It  will  have  been  noticed  that  leptomeningitis  is  found  in  fre- 
quent association  with  the  other  infectious  diseases.  Cnrschmann  has 
noted  it  in  small-pox  and  scarlatina,  both  with  and  without  purulent 
otitis.  It  is  not  rare  after  typhoid.  It  is  common  with  pneumonia. 
All  pyemias,  whatever  their  source,  have  their  recorded  cases.     Acute 

1  "Centralbl.  f.  Bakt.  u.  Parasitenkunde,"  April,  1895. 

2  "Am.  Jour.  Med.  Sei.,"  Feb.,  1894. 

3  Daddi,  "  Lo  Sperimentale, "  July,  1894.  Ohlmacher,  "Jour.  Am.  Med.  Assn.," 
Aug.  28,  1897. 

■*Gynn,  "Phila.  Med.  Jour.,"  vol.  ii,  No.  24. 


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INFLA3IMATI0N  OF  THE  PI  A  MATER.  79 

articular  rheumatism  is  frcqueutly  attended  })y  meningeal  symptoms 
which  are  customarily  attributed  to  rheumatic  inflammation  of  the 
serous  brain-envelope,  but  Ball/  in  at  least  3  out  of  69  such  eases, 
found  a  purulent  effusion,  and  serous  exudation  was  present  in  35. 
Mumps  are  often  associated  with  meningitis  and  epidemics  of  both  have 
been  concurrently  noted.  The  same  is  true  of  coryza,  which,  like  paro- 
titis, is  sometimes  undoubtedly  due  to  the  lancinate  micrococcus.  A 
most  marked  relationship  exists  between  pneumonia,  influenza,  and  men- 
ingitis. They  may  follow  one  another  in  a  given  patient.  They  are 
apparently  interchangeable  in  a  grippal  epidemic,  and  present  remark- 
able bacterial  analogies.  In  pneumonia  of  the  apex  a  meningitic 
disturbance  sometimes  arises  that  is  not  marked  anatomically  Ijy  any 
evidence  of  inflammation.  Cultures  in  such  cases  have  also  been 
negative.  2  The  clinical  picture,  however,  is  that  of  acute  meningitis, 
and  further  investigation  may  yield  positive  findings.  The  so-called 
acute  serous  meningitis  is  generally  secondary  to  some  pyemic  con- 
dition, and  in  some  instances  the  clear  meningeal  fluid  has  contained 
streptococci.  ^  Insolation  is  undoubtedly  at  times  attended  by  a  menin- 
geal congestion  that  may  develop  into  active  inflammation  with  a  ten- 
dency to  chronic  changes. 

Pathological  Anatomy. — The  pathological  changes  in  the  nieninges 
are  more  or  less  circumscribed  when  due  to  infection  by  extension,  and 
are  then  limited  to  the  neighborhood  of  the  primary  lesion.  On  the 
other  hand,  infection  by  way  of  the  circulation  gives  rise  to  a  general- 
ized meningitis  which  is  most  intense  at  the  vertex  of  the  hemispheres 
and  may  completely  spare  the  basal  region.  The  dura  mater,  except  at 
the  site  of  bone  disease  or  similar  infection  center,  is  practically  intact 
and  is  readily  removed.  The  pia  presents  a  roughened,  marbleized  ap- 
pearance. The  vessels  are  engorged  with  blood  and  the  pial  spaces  are 
filled  with  a  serous,  milky,  or  purulent  exudate,  which  follows  the  vas- 
cular courses,  fills  the  sulci,  and,  if  sufliciently  abundant,  unbrokenly 
covers  the  convolutions.  At  other  times  the  exudate  appears  in  discrete 
patches,  which  are  for  the  most  part  found  at  the  basilar  outlets  of  the 
cranial  nerves  and  vessels.  Extensions  sometimes  accompany  the 
auditory  nerve  into  the  internal  meatus  or  follow  the  optic  nerve  into 
the  orbit.  The  seropurulent  deposit  is  more  or  less  fibrinous,  and  the 
serous  exudate  sometimes  is  filled  with  flaky  masses,  which  escape  with 
it  when  the  skull  is  opened.  Ordinarily  the  inflammation  follows  the 
choroid  plexuses  into  the  ventricles,  which  are  oftentimes  dilated  by  the 
increased  turbid,  flocculent,  pial  fluid. 

The  cerebral  cortex,  in  cases  of  short  duration  and  in  the  so-called 
serous  form,  may  show  little  more  than  the  evidence  of  increased  vascu- 
larity. In  severe  and  protracted  cases  minute  hemorrhages  are  com- 
mon, both  in  the  pial  spaces  and  the  brain-substance.  The  perivascular 
sheaths  are  blocked  with  exudate,  and  the  cortex  is  edematous,  infil- 
trated with  pus,  and  adherent  to  the  pia,  which  can  not  be  separated  from 

1  "Thfese  de  Paris,"  1869. 

^Berge,  Claisse,  "  Traite  de  Medecine,"  vol.  vi,  p.  529,  Paris,  1894. 

*  Nobecourt and Delestre,  "Annalesde  Med.  et  de  Chir.  Infantiles,"  April  15,  1900. 


80  DISEASES  OF  THE  CEREBRAL  3IENINGES. 

it  without  stripping  off  the  gyral  substance.  Thrombotic  softening  and 
abscess  formation  may  follow. 

The  cord  is  affected  in  about  one-third  of  the  cases.  Its  meningeal 
and  deeper  conditions  are  similar  to  those  of  the  cerebrum.  The  pos- 
terior roots  seem  especially  vulnerable,  and  present  marked  inflamma- 
tory and  degenerative  changes  of  their  hyaline  and  axis-cylinder  ele- 
ments. The  exudate  is  usually  thicker  on  the  posterior  surface  of  the 
cord,  probably  from  the  usual  dorsal  position  of  the  patient.  This  may 
also  account  for  the  preponderance  of  changes  in  the  posterior  part  of 
the  cord. 

From  the  gross  appearance  it  is  evident  in  severe  cases  that  men- 
ingitis is  attended  by  a  certain  degree  of  cerebj'itis.  The  anatomy  of 
the  meninges  explains  this.  The  histological  changes  consist  of  cap- 
illary and  vascular  dilatation  in  the  pia  and  an  active  diapedesis  into 
the  perivascular  sheaths.  These  are  dilated  and  crowded  with  leuko- 
cytes and  purulent  elements.  The  neurogliar  cells  and  network  of  the 
cortex  show  some  proliferation.  The  bacteriology  has  already  been  in- 
dicated. 

The  body  organs  show  the  varying  lesions  of  the  primary  disease, 
such  as  typhoid,  pneumonia,  infectious  endocarditis,  or  local  septic  pro- 
cesses. Splenic  enlargement  may  alone  mark  the  infectiousness  of  the 
disease. 

Symptoms. — The  incubation  period  of  meningitis  is  an  indefinite 
one.  In  some  epidemics  it  has  appeared  to  be  somewhat  less  than  a 
week.  In  the  fulminant  cases  the  severest  manifestations  of  the  disease 
are  present  almost  in  a  moment,  and  death  may  occur  in  twenty-four  hours. 
Usually  there  is  an  invasion  period  of  several  days  or  weeks,  attended 
by  malaise,  discomfort,  slight  feverishness,  and  headache.  More  pro- 
nounced disturbance  then  ensues,  and  we  have  a  varying  period  of  ex- 
citement, followed  by  one  of  depression,  stupor,  coma,  and  death. 

The  prodromal  headache  becomes  severe,  continuous,  and  of  all  the 
symptoms  is  the  most  constant  and  significant.  It  is  particularly  vio- 
lent and  unmanageable.  The  patient  constantly  complains  of  it,  and 
when  stupor  or  coma  has  supervened,  by  holding  the  head  in  the  hands 
and  by  moans  and  facial  expression,  he  still  indicates  its  often  overmas- 
tering presence.  In  children  it  gives  rise  to  the  sharp  cephalic  cry  that 
punctuates  their  stuporous  state  at  frequent  intervals.  Ordinarily  it  is 
referred  to  the  occiput  or  vertex,  but  is  often  diffuse. 

Delirium  is  common  in  children  and  frequent  in  adults.  A  mental 
fogginess  is  often  early  noticeable.  The  patient,  racked  by  the  cephal- 
algia, seems  irresponsive,  unimpressionable,  and  is  hazy  in  his  replies. 
The  delirium  is  of  a  low  grade  generally,  but  may  be  wild  and  frantic  or 
suggestive  of  the  busy  delirium  of  alcoholism  and  typhoid.  Vomiting 
of  a  projectile  character  is  rarely  absent  in  children,  but  is  less  common 
in  adults.  The  stomach  seems  simply  intolerant  and  rejects  without 
nausea  the  unchanged  ingesta.  It  may  be  an  early  symptom.  At  the 
same  time  the  tongue  may  be  quite  clean;  later  it  is  often  thickly  furred 
and  suggestive  of  typhoid.  The  bowels  are  usually  constipated  and  the 
abdomen  retracted. 


INFLAMMATION  OF  THE  PI  A  MATER.  81 

Convuhlons  in  the  early  stages,  particularly  in  cliiklren,  often  occur. 
They  are  general  in  character  and  of  protracted  duration.  When  the 
convexity  is  invaded,  they  may  later  present  a  limited  distribution,  one 
side  of  the  body,  the  face,  or  a  single  extremity  being  alone  involved. 

Almost  invariably  there  is  more  or  less  muscular  rigidity.  In  most 
cases   this  is  marked  at  the  neck  bv  a  tendency  to  retraction  that  is 


Fig.  27. — Attitude  of  child  with  cerebrospinal  meningitis  (Smith). 

liighly  significant.  At  first  the  patient  complains  of  a  feeling  of  nuchal 
stiffness  and  soreness,  and  finds  slight  relief  in  resting  the  head  on  a 
chair-back  or  over  a  firm  pillow.  In  the  comatose  condition  the  head 
is  often  strongly  retracted  and  the  occiput  drawn  well  between  the 
shoulders.  When  less  marked,  an  attempt  to  passively  bring  the  head 
forward  will  provoke  distress  and  resistance.  A  similar  rigidity  rarely 
invades  the  muscles  of  the  lower  jaw,  producing  slight  trismus.  It  may 
involve  the  extremities,  and  when  the  meningitis  has  attacked  the  spine 
the  trunk  is  often  held  rigidly  in  a  position  of  dorsal  extension.  Ker- 
nig  and  Bull  ^  have  described  a  peculiar  rigidity  in  the  lower  limbs.  If 
the  patient  is  placed  in  a  chair  he  is  unable  to  extend  the  knees  owing 
to  the  contracture,  which  disappears  when  the  thigh  is  straightened  on 
the  trunk.  According  to  Herrick,  Osier,  and  others,  this  sign  is  practi- 
cally constant  in  this  disease.  It  appears  early  and  is  certainly  valuable. 
Muscular  weakness  is  usually  present  and  may  be  more  or  less  localized. 
The  cranial  nerves  in  most  cases  sooner  or  later  show  invasion  and 
furnish  valuable  diagnostic  symptoms.  The  olfactory  nerves  are  seldom 
disturbed,  but  occasionally  the  patient  complains  of  olfactory  sensitive- 
ness. Photophobia  is  a  common  symptom.  The  optic  nerve  is  irritated 
by  extension  of  the  inflammation  down  its  sheath.  After  a  few  days 
liaziness  of  the  disc  and  enlarged  vessels  are  often  seen  oj^hthalmoscop- 
ically.  The  disc  may  be  markedly  obscured.  Retinal  hemorrhages, 
papillitis,  and  subsequent  atrophy  and  blindness  are  occasionally  en- 
countered. Choroiditis,  or  panophthalmitis,  is  sometimes  present  and 
may  cause  great  injury  to  the  eye  or  result  in  complete  blindness.  The 
third  nerve  is  almost  always  affected.  AYhen  marked  strabismus  does 
not  demonstrate  it  at  a  glance,  by  having  the  patient  turn  the  eyes  in 
Tarious  directions  a  lack  of  conjugate  action  becomes  apparent.  Question- 
1  "Berlin,  klin.  Wochens.,"  1895. 
6 


82  DISEASES  OF  THE  CEREBRAL  MENINGES. 

ing  may  develop  the  history  of  visual  uncertainties — haziness  or  transient 
diplopia.  The  pupih  also  furnish  important  signs.  Early  in  the  at- 
tack there  is  a  tendency  to  miosis,  which  later  is  replaced  by  pupillan.' 
dilatation.  The  reflex  to  light  is  lost  or  greatly  reduced  in  amplitude 
or  activity.  The  pupils  may  be  perfectly  immovable.  They  are  often 
unequal.  The  facial  nerve  is  exceptionally  paretic,  allowing  the  face  to 
deviate  to  the  opposite  side.  At  the  same  time  the  auditory  nerve  is 
implicated  through  its  association  with  the  facial  nerve  within  the  bony 
w^alls  of  the  internal  meatus.  The  loss  of  hearing  that  sometimes  fol- 
lows cerebral  meningitis  is  due  piincipally  to  an  extension  of  the  inflam- 
mation to  the  labyrinth,  and  only  exceptionally  to  destruction  of  the 
auditory  nerve-trunk.  Irritation  of  the  auditory*  apparatus  is  appar- 
ent in  the  early  stages  of  the  attack.  All  sudden  or  loud  noises  greatly 
distress  the  patient.  Implication  of  the  hypogJossus  in  rare  cases  causes 
deviation  of  the  tongue.  Probably  all  other  cranial  nerves  are  similarly 
aifected.  Doubtless  the  common  respiratory  and  cardiac  disturbances 
are,  at  least  sometimes,  attributable  to  injury  of  the  pneumogastric. 

In  addition  to  tlie  hyperesthesia  of  the  special  senses  much  tenderness 
is  customarily  found  over  the  spine  and  limbs.  The  back  of  the  neck 
is  especially  sensitive,  and  firm  pressure  of  the  muscular  masses  is  usually 
resented.  The  entire  head  is  more  or  less  sensitive  to  deep  pressure, 
and  pain  is  provoked  by  gentle  j^ercussion  over  the  skull.  The  paretic 
and  sensory  disturbances  may  be  unilateral  or  monoplegic  in  distribution. 
The  location  of  the  disease  causes  these  variations. 

Cerebral  meningitis  presents  no  characteristic  tempjero.iure  curve.  It 
may  be  ushered  in  by  a  chill  and  an  elevation  of  the  body-heat  to  104° 
or  higher.  It  may  show  a  very  low,  even  a  subnormal,  temperature  at 
first,  and  terminate  with  a  high  range.  The  evening  rise  may  default. 
Fickleness  is  the  rule  and,  in  a  way,  diagnostic. 

The  pndse  shows  variation  in  two  directions.  During  the  early  stage 
of  excitement  it  is  likely  to  be  full,  active,  and  greatly  accelerated. 
Not  uncommonly,  however,  the  physician  is  surprised  to  find  a  slug- 
gish pulse  of  40  or  60  and  the  temperature  mounting  above  100°. 
This  dissociation  of  pndse  and  temperature  is  usually  manifest  sooner  or 
later  in  meningitis,  and  furnishes  a  sign  of  capital  importance.  Toward 
the  fatal  end  the  temperature  bounds  upward,  attended  l^y  a  pulse  of 
great,  almost  uncountable,  rapiditA\ 

Vasomotor  signs  are  not  lacking.  Herpes  lahialis  is  as  common  as  in 
pneumonia  and  as  significant.  If  the  finger-nail  be  drawn  across  the 
integument  of  the  abdomen  or  elsewhere,  it  is  followed  slowly  by  a  con- 
gested red  streak  that  persists  for  many  minutes.  Trousseau  laid  much 
stress  on  the  phenomenon,  which  he  called  the  tache  eerehrale,  and  it  is  of 
'some  significance.  Taken  alone  it  is  of  no  importance,  as  it  is  common 
to  many  conditions.  The  application  of  mild  irritants  or  gentle  heat  is 
likely  to  be  followed  by  vesiculation  and  sloughing.  Uiiicaria  is  often 
present.  A  red  'macular  eruption  which  gives  to  cerebral  meningitis  its 
sometime  name  of  spotted  fever  is  of  infrequent  occurrence.  It  appears 
mainly  on  the  abdomen  and  trunk,  and  may  be  mistaken  for  the  pete- 
chial marking  of  typhoid  fever.      It  is  more  like  roseola. 


INFLAMMATION  OF  THE  PI  A  MATER. 


83 


Early  in  the  attack  the  respiration  may  be  quickened.  Later,  in  the 
stupor  and  coma,  it  is  often  slow  and  irregular.  The  Cheyne-Stokes 
variety  is  often  observed,  and  is  of  very  serious  though  not  absolutely 
of  fatal  import.  The  ordinary  relations  of  respiration  to  the  tempera- 
ture and  pulse  may  be,  and  often  are,  disturbed. 

The  urine  shows  the  general  febrile  disturbance,  and  is  scanty,  high- 
colored,  and  heavy.  Sometimes  albumin  and  sugar  are  found  in  quan- 
tities varying  from  a  trace  to  large  amounts.  They  are  significant  of 
irritation  of  the  medullary  centers  in  the  floor  of  the  fourth  ventricle. 

The  tendon-reflexes  may  or  may  not  be  much  modified.  Sometimes  they 
are  exaggerated,  more  often  decreased.  It  is  not  uncommon  to  find  them 
diminishing  as  the  depressed  stage  comes  on.  Their  obliteration  after 
the  disease  has  lasted  a  week  or  ten  days  in  protracted  cases  is  often 
noticed.       They  may  be  more  disturbed  on  one  side  than  on  the  other. 


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Fig.  28. — Partial  temperature-  and  piilse-ciirves  in  a  case  of  meningitis  of  the  convexity,  showing 
dissociation.  Temperature,  upper  line ;  pulse,  lower  line.  Eecord  taken  every  four  hours,  commencing 
at  midnight. 


Course. — No  two  cases  present  parallel  conditions  as  to  course, 
symptoms,  or  intensity.  A  fulminant  case  may  end  fatally  in  a  day. 
Protracted  cases  extend  over  several  weeks  and  some  are  clearly  sub- 
acute. An  ordinary  non-epidemic  case  presents  perhaps  a  week  of 
malaise,  a  week  of  excitement,  and  a  week  of  depression,  which  usually 
terminates  in  deepening  coma  and  death  by  cardiac  failure.  At  any 
time,  even  when  the  patient  seems  to  be  in  extremis,  the  symptoms  may 
clear  away  and  convalescence  follow.  A  remission  of  symptoms  may 
give  false  hope,  to  be  destroyed  by  the  return  of  the  serious  features  of 
the  disease  in  all  their  intensity.  When  the  basilar  region  is  principally 
aifected,  the  course  of  the  disease  is  likely  to  be  cut  short  by  bulbar  in- 


84  DISEASES  OF  THE  CEREBRAL  3IENINGES. 

vasion.  The  convexity  cases  are  of  longer  duration  and  the  patient  thus 
aflPected  is  sometimes  gradually  worn  out  by  the  pain,  delirium,  and  fever. 

During  the  period  of  excitement  of  functions,  vomiting,  delirium, 
vertigo,  high  temperature,  muscular  rigidity,  spasms,  convulsions,  inde- 
terminate headaches,  and  hyperesthesia  are  the  prominent  features. 
They  are  gradually  replaced  by  increasing  apathy,  stupor,  and  coma,  in 
which  the  patient  lies  inert.  He  may  be  nearly  relaxed  or  lie  with 
retracted  head,  marked  squint,  and  rigid  limbs,  passing  urine  and  feces 
under  him,  and  responding  to  strong  stimulation  slightly  or  not  at  all. 
The  rapid  respiration  of  the  first  period  is  replaced  by  the  slow  or 
irregular  breathing  that  indicates  increased  intracranial  pressure  or 
pneumogastric  irritation.  Finally,  deglutition  is  impaired,  respiration 
becomes  stertorous,  and  the  patient  slowly  sinks  or  may  expire  in  a 
convulsion. 

Various  epidemics  have  shown  numerous  features  of  similarity 
among  the  cases  that  have  marked  their  progress.  At  first  the  fulmi- 
nant cases  have  been  common.  At  the  end  those  of  less  and  less  sever- 
ity are  met  with. 

Diagnosis  in  the  very  early  stage  is  difficult.  When  the  disease  is 
fully  developed,  and  in  epidemic  conditions,  a  mistake  would  be  almost 
impossible.  No  one  symptom  is  constant,  and  it  is  a  disease  of  protean 
aspects.  The  symptoms  vary  as  the  base  or  convexity  is  involved. 
Meningitis  of  the  convexity  is  marked  by  excessive  delirium,  high  tem- 
perature, convulsions,  localized  spasm,  dysesthesia,  and  monoplegias. 
The  cranial  nerves  are  not  involved,  and  ocular  symptoms  are  slight  or 
entirely  wanting. 

When  the  base  is  affected,  the  temperature  often  has  a  low  range  or 
is  subnormal.  Cranial  palsies  are  common,  retraction  of  the  head  is 
nearly  always  present,  and  the  dissociation  of  pulse,  temperature,  and 
respiration  is  marked.  Optic  neuritis  declares  the  basilar  location  or 
extension  of  the  disease.  As  a  rule,  infection  by  the  blood-channels 
results  primarily  in  meningitis  of  the  convexity.  In  rare  instances  the 
meningitis  is  confined  to  the  ventricular  area  and  the  choroid  append- 
ages, but  no  distinctive  symptoms  indicate  this  limitation.  The  diag- 
nostic value  of  the  headache  depends  upon  its  duration,  intensity,  and 
particularly  upon  its  persistence  after  delirium  has  appeared  or  coma 
has  ensued.  The  tenderness  of  the  head  and  the  pain  on  pressure  are 
of  some  value.  Vomiting  is  only  significant  when  of  the  projectile 
character,  unattended  by  gastric  disturbance  and  fermentative  changes. 
The  temperature  lends  aid  when  out  of  keeping  with  the  pulse-rate  and 
respiration  rhythm.  The  tenderness  in  the  limbs,  the  rigidity  of  the 
neck,  the  contractures  at  the  knee  in  the  sitting  attitude,  are  highly 
suggestive.  Apathy,  drowsiness,  and  mental  obscuration  in  themselves 
should  suggest  the  disease.  The  grouping  of  several  of  these  symp- 
toms would  justify  a  tentative  diagnosis,  which  the  appearance  of  squint, 
convulsions,  delirium,  optic  neuritis,  Kernig's  sign,  or  the  vasomotor 
symptoms  would  confirm.  Gowers  states  that  in  suspected  cases  the  too 
free  vesiculatiou  of  the  skin  under  heat  or  irritation  would  lend  support 
to  the  diagnosis  of  meningitis.     Lumbar  puncture  will  also  assist. 


INFLAMMATION  OF  THE  PI  A  MATER.  85 

Diiferentially,  the  diagnosis  is  often  much  complicated  by  the  associa- 
tion of  meningitis  with  other  aifections  which  may  overshadow  it.  As 
it  occurs  in  the  course  of  pneumonia,  typhoid  fever,  cranial  injuries, 
septic  invasion,  and  pyemias,  the  original  disease  process  may  entirely 
absorb  the  practitioner's  attention.  From  typhoid,  Hirt  ^  says,  it  is 
sometimes  indistinguishable,  presenting  a  similar  temperature  curve, 
splenic  enlargement,  rose  spots,  and  the  typhoid  stool.  The  presence  of 
pseudomeningeal  symptoms  in  pneumonia  of  the  apices  has  been  men- 
tioned, and  in  pneumonia  generally  meningitis  can  only  be  determined 
by  basilar  symptoms.  Uremia  should  be  excluded  by  a  thorough 
urinalysis.  An  attack  of  delirium  tremens  may  be  easily  mistaken  for 
meningitis,  with  which  it  is  not  rarely  complicated.  Single  or  double 
acute  otitis  in  children,  marked  by  constant  pain  and  vomiting,  delirium, 
and  deafness,  is  usually  confounded  with  meningitis.  If  the  facial 
nerve  escape,  the  deafness  would  point  to  labyrinthian  disease  and  serve 
to  exclude  meningitis.  Hysteria  is  sometimes  mistaken  for  meningitis. 
The  emotional  and  mental  features,  the  normal  temperature,  breathing, 
and  pulse,  and  certainly  the  stigmata  of  hysteria  should  diiferentiate  it. 
In  children  the  onset  of  nearly  every  febrile  disturbance  has  been  con- 
founded with  meningitis.  Here  reliance  must  be  placed  on  the  charac- 
teristic temperature  curves,  eruptions,  and  clinical  antecedents. 

Prognosis. — In  expressing  an  opinion  as  to  the  outcome  of  a  given 
case,  the  physician  has  three  positive  statements  to  make.  First,  the 
result  is  absolutely  uncertain  until  death  occurs  or  convalescence  is 
firmly  established  ;  second,  the  probability  of  a  fatal  termination  is 
always  pronounced  ;  third,  some  trace  of  the  disease  is  likely  to  remain 
permanently.  The  disease  is  full  of  surprises.  The  writer  has  seen 
a  patient  in  deepest  coma  for  hours,  with  convergent  squint  of  the 
most  marked  variety,  retracted  head  and  abdomen,  convulsed  limbs,, 
Cheyne-Stokes  respiration,  large  quantities  of  sugar  in  the  urine,  and  a 
pulse  of  32,  entirely  recover.  Again,  cases  that  seem  trifling  or  on 
the  high  road  to  recovery  suddenly  become  worse  and  die.  Purulent 
cases  are  practically  always  fatal.  If  a  purulent  focus  within  the  skull, 
nose,  ear,  or  throat  is  found,  it  renders  the  outlook  extremely  grave. 
A  meningitis  following  pneumonia  is  practically  fatal,  but  Stoeltzner  ^ 
reports  a  recovery  where  spinal  puncture  showed  both  pus  and  the 
pneumococcus.  The  cerebrospinal  form  runs  a  more  favorable  course, 
the  mortality  varying  from  about  thirty  to  sixty  per  cent,  in  various 
epidemics.  Partial  recoveries,  however,  greatly  outnumber  cures.  The 
extension  of  inflammation  to  the  labyrinth  produces  deafness,  which  in 
young  children  may  lead  to  deaf-mutism.  Optic  neuritis  is  followed  by 
dimness  of  sight  or  complete  blindness.  Local  meningeal  thickenings 
and  cerebritis  portend  monoplegias,  epileptoid  convulsions,  and  mental 
defect.  Though  the  disease  is  not  one  of  proved  contagiousness,  sepa- 
ration of  the  patient  from  the  other  members  of  the  family  may  be 
insisted  upon  with  propriety.  The  tubercular  variety  is  almost  in- 
variably fatal. 

^  Hirt,  "  Diseases  of  the  Nervous  System,"  New  York,  1893. 
2  "Berlin,  klin.  Wochens.,"  April  19,  1897. 


86  DISEASES  OF  THE  CEREBRAL  MENINGES. 

Treatment. — The  first  consideration  in  the  management  of  a  case 
is  the  removal,  if  possible,  of  the  infection  atrium.  Cranial  suppura- 
tion and  injuries  demand  immediate  surgical  attention.  Optic,  nasal, 
pharyngeal,  intestinal,  and  pelvic  cavities  should  be  rendered  aseptic  if 
their  organs  or  contents  fall  under  suspicion.  Intestinal  antisepsis  is 
always  in  order.  To  this  end  free  catharsis  and  the  administration  of 
antifermentatives  are  indicated  as  well  as  by  the  usual  constipation. 
Minute  doses  of  calomel,  ^  of  a  grain,  repeated  every  half  hour  or 
hour  until  active  results  are  obtained,  can  be  highly  recommended 
for  this  purpose.  In  addition,  the  mercurial  has  a  widely  diffused  mi- 
crobicidal value. 

From  the  first  the  patients  should  be  kept  in  a  cool,  quiet,  moder- 
ately darkened  room,  and  all  annoyances  to  which  their  hyperesthetic 
senses  make  them  especially  responsive  should  be  prevented.  Extreme 
delirium  will  often  require  a  sedative.  In  the  presence  of  the  cephal- 
algia bromids,  chloral,  Indian  hemp,  and  other  ordinary  means  will 
practically  always  fail.  The  coal-tar  derivatives  are  equally  valueless, 
and  nothing  but  morphin  will  give  relief.  Its  hypodermatic  admin- 
istration is  by  all  odds  to  be  preferred  except  in  infants.  If  high  tem- 
perature be  present,  antipyretic  drugs  must  be  employed  with  great 
circumspection.  They  often  have  no  effect,  and  their  depressing  action 
sometimes  constitutes  a  real  danger  in  a  disease  marked  by  symptoms 
of  disturbed  cardiac  and  respiratory  innervation.  Tepid  to  cool  baths 
with  cold  affusions  to  the  head,  sponging,  and  the  pack  may  be  used  to 
better  advantage.  Hot  baths  are  decidedly  valuable.  They  often  allay 
the  delirium,  reduce  the  temperature,  and  clear  up  the  clouded  mind. 
The  use  of  an  ice-bag  or  ice-coil  to  the  head  frequently  gives  comfort  to 
the  patient  and  renders  the  head-pain  bearable.  Counterirritation  along 
the  spine  is  a  measure  of  doubtful  utility,  and  always  attended  by  the 
danger  of  setting  up  serious  ulceration  or  actual  sloughing. 

In  the  depressed  period  sedatives  are  no  longer  required,  and  stimu- 
lants, like  strychnin  and  whisky,  will  often  need  to  be  sharply  pushed 
to  meet  the  failing  action  of  the  heart  or  lungs.  When  coma  has 
appeared,  it  may  often  be  broken  and  sometimes  happily  ended  by  the 
application  of  a  fly-blister  to  the  nape  of  the  neck.  It  should  be  suffi- 
ciently large, — two  by  six  inches  for  an  adult, — and  extend  from  one 
mastoid  to  the  other.  If  this  is  not  efficacious  or  the  coma  again  develop, 
a  drastic  cathartic — one  to  five  droj)s  of  croton  oil  in  emulsion — may 
render  similar  service.  By  recurring  in  turn  to  the  blister,  cathartic, 
and  baths,  with  cool  affusions  to  the  head,  no  doubt  the  progress  of  the 
disease  may  be  often  hindered.  Unfortunately,  it  usually  again  takes  up 
its  course,  but  occasionally  such  measures  seem  to  definitely  clieck  the 
malady  and  recovery  slowly  follows.  Aufrecht  ^  recommends  full  hot 
baths  of  about  100°  F.  for  ten  minutes.  Their  apparent  effect  some- 
times is  to  reduce  temperature,  diminish  the  headache,  accelerate  the 
pulse,  and  induce  sleep.  As  many  as  eight  a  day  have  been  given  with 
excellent  results  by  Woroschilsky .  ^ 

1  "Therap.  Monatshef te, "  Aug.,  1894.  "^ IMd.,  Feb.,  1895. 


INFLAMMATION  OF  THE  PI  A  MATER.  87 

The  use  of  large  doses  of  iodids  with  the  expectation  of  causing  re- 
sorption of  the  effusion  usually  only  results  in  distressing  the  patient's 
stomach,  reducing  his  strength,  and  increasing  the  vomiting.  Shaving 
the  head  is  rarely  called  for,  but  a  heavy  mass  of  hair  may  usually  be 
removed  with  advantage.  Mercurial  inunctions  seem  at  times  to  lend 
help  even  in  the  absence  of  syphilitic  taint.  It  is  immaterial  whether 
they  be  applied  to  the  scalp  or  to  the  limbs,  so  far  as  the  eifect  is  con- 
cerned, but  the  non-hairy  parts  are  more  convenient  and  less  irritable. 
Crede's  colloid  of  silver  ointment  and  iodoform  ointment  in  large  doses 
applied  to  the  head  have  advocates,  and  may  be  properly  employed.  Good 
results  have  been  claimed  for  subcutaneous  injection  of  the  bichlorid 
of  mercury  in  doses  of  ^  of  a  grain  several  times  a  day  in  children. 

The  most  important  items  in  the  treatment  of  meningitis  are  the  nurs- 
ing and  nutrition  of  the  patient.  A  careful,  intelligent,  preferably  trained, 
nurse  who  will  exclude  visitors  and  members  of  the  family  and  prevent 
disturbing  sounds,  bright  lights,  and  all  annoyances,  is  the  salvation  of 
some  cases.  Thus  only  can  constant  watchfulness  of  pulse,  respiration, 
and  temperature,  which  may  show  extreme  and  critical  variations  in  an 
hour,  be  provided  and  emergencies  met  as  they  arise.  Nourishment  in 
small  quantities  can  usually  be  administered  frequently.  If  the  cerebral 
vomiting  persist,  morphin  is  practically  the  only  measure  we  can  rely 
upon  to  check  it.  In  the  stuporous  states  rectal  alimentation  will  be 
serviceable,  or  the  nasal  stomach-tube  in  skilled  hands  may  be  employed. 
If  deglutition  is  difficult,  one  of  these  is  imperatively  demanded.  Large 
quantities  of  soups,  custards,  whey,  junket,  beef-juice,  and  eggs  may  be 
given  with  advantage  from  first  to  last.     The  bowels  must  be  active. 

The  question  of  trephining  the  cranium  and  draining  the  meninges 
and  ventricles  has  received  favorable  consideration  in  those  cases  where 
deepening  coma  and  failing  circulation  point  to  increasing  intracranial 
pressure.     The  results  thus  obtained,  however,  are  not  encouraging. 

Quincke,  in  1891,  suggested  that  the  intracranial  pressure  could  be 
easily  relieved  by  puncturing  the  dural  sheath  of  the  lumbar  cord  with 
a  hollow  needle.  The  procedure  has  since  been  widely  adopted.  Fur- 
bringer  ^  used  the  lumbar  puncture  one  hundred  times  in  eighty-six 
cases.  In  many  of  his  non-tubercular  cases  sugar  was  found  in  the 
spinal  fluid,  but  only  exceptionally  in  tubercular  meningitis.  The 
presence  of  pus  or  tubercle  bacilli  or  other  organisms  in  many  in- 
stances completed  the  diagnosis.  In  several  cases  in  children  a 
sinking  of  the  fontanel  showed  that  the  intracranial  pressure  was  re- 
duced. A.  Fraenkel  ^  has  noticed  the  optic  papillitis  diminish  and 
improvement  in  other  symptoms  after  the  puncture.  The  writer  has 
observed  a  pulse  of  160  drop  twenty  beats  in  an  adult  upon  the  re- 
moval of  two  ounces  of  fluid.  As  a  means  of  diagnosis  it  has  a  pre- 
cise value  when  positive  findings  are  furnished,  but  therapeutically  has 
not  accomplished  much.  In  principle  it  seems  seductively  correct,  and 
in  a  disease  of  such  fatal  character  may  be  employed  in  suitable  cases 
with  proper  surroundings  when  pressure  symptoms  are  marked.     The 

1  "Berlin,  klin.  Wochens.,"  April  1,  1895.  ''Ihid. 


88  DISEASES  OF  THE  CEREBRAL  MENINGES. 

operation  is  a  simjsle  one.  It  is  best  performed  with  the  patient  in  a 
sitting  position,  the  back  bent  well  forward,  thereby  opening  the  spaces 
between  the  lumbar  spines.  Under  full  asepsis  a  hollow  needle  of  one 
and  one-half  millimeters  is  introduced  from  without  inward,  about  an  inch 
from  the  middle  line  between  the  third  and  fourth  lumbar  spines.  This 
level  is  below  the  cord.  The  fluid  at  first  usually  flows  rapidly,  but 
later  drop  by  drop  and  shows  the  influence  of  respiratory  pressure.  The 
amount  withdrawn  has  varied  from  a  few  drops  to  several  ounces.  The 
puncture  may  be  repeated  as  required. 

One  danger  of  lumbar  puncture  is  pointed  out  by  Jacoby,i  who  sug- 
gests that  where  the  meningitic  process  is  confined  to  the  cerebrum 
draining  by  the  lumbar  puncture  may  carry  the  infection  down  the  cord, 
and  thereby  extend  the  disease.  He  also  shows  conclusively  that  it  is 
impossible  from  the  lumbar  extremity  to  force  fluids  of  a  therapeutic 
character  into  the  arachnoid  spaces  above  the  cervical  region,  unless 
puncture  is  also  made  into  the  ventricular  space  of  the  brain,  when  the 
fluid  passes  very  readily  from  one  end  to  the  other  of  the  cerebrospinal 
meninges.  He  advocates  such  flushing  of  the  cerebrospinal  axis  by 
means  of  both  the  lumbar  puncture  and  a  small  trephine  opening  with 
drainage  from  the  lateral  ventricle. 

In  recovered  cases  treatment  is  directed  toward  building  up  the 
general  health.  Inflammatory  thickening  and  remaining  effusion  may 
perhaps  be  benefited  by  iodid  of  potassium  and  mild  mercurial  courses. 
Weakened  or  paralyzed  extremities  should  receive  careful  electrical  and 
massage  treatment  as  soon  as  the  active  febrile  stage  subsides.  All 
severe  physical  and  mental  fatigue  should  be  avoided  for  a  long  period. 
Exposure  to  the  sun  and  the  use  of  stimulants  will  be  found  especially 
detrimental. 

Chronic  Leptomeningitis. — Leptomeningitis,  as  already  men- 
tioned, is  occasionally  subacute.  This  form  may  become  chronic.  As 
the  result  of  alcoholic  excesses,  syphilis,  and  insolation,  sometimes  a  low 
grade  of  chronic  leptomeningitis  is  developed.  Post-mortem  examina- 
tion frequently  reveals  such  a  condition  which  may  have  been  unsus- 
pected during  life.  Among  the  chronic  insane  it  is  a  very  common 
finding  after  death.  Clinically,  except  in  the  syphilitic  form,  its  mani- 
festations are  very  uncertain  and  obscure.  Stiffness  of  the  neck  and 
persistent  slight  headache,  both  marked  by  exacerbations,  with  some 
tenderness  over  the  skull,  may  be  complained  of.  Undue  optic  and 
auditory  sensitiveness  usually  accompany  the  more  severe  periods  of 
headache.  All  causes  of  cerebral  congestion,  such  as  stooping  and 
muscular  or  m.ental  exertion,  cause  distress  and  intensify  the  headache. 

The  alcoholic  cases  are  the  least  well  marked.  A  low  grade  of  optic 
neuritis  may  be  present,  and  usually  disappears  if  the  alcohol  is  with- 
drawn. Slight  mental  cloudiness  or  delirium,  due  to  the  specific  action 
of  the  poison  on  the  brain-tissue,  is  frequently  observed.  Multiple 
neuritis  and  other  indications  of  alcoholism  are  usually  present,  and 
often  quite  overshadow  the  meningeal  svmptoms. 

The  syphilitic  inflammation  is  usually  circumscribed,  and  gives  rise 
1  "New  York  Medical  Journal,"  1895. 


TUBERCULAR  MENINGITIS.  89 

to  local  symptoms.     It  will   be  fully  considered  under  the  head  of 
Syphilis  of  the  Nervous  System,  Part  VI. 

A  chronic  infantile  meningitis  has  been  described  in  which  the  menin- 
geal involvement  is  confined  to  tlie  posterior  basal  fossae  of  the  skull.  It 
may  last  from  a  month  to  several  years,  and  terminate  in  death  or  re- 
covery. Its  onset  is  sometimes  sudden,  and  has  been  shown  in  certain 
cases  to  depend  on  hemorrhage  about  the  medulla  and  pons.  In  other 
cases  it  is  of  gradual  development.  Palsies  are  rare ;  retraction  of  the 
head  and  strabismus  are  common.  Through  damming  up  of  the  ven- 
tricular outlet,  hydrocephalus  may  be  induced. 


CHAPTER  III. 
TUBERCULAR  MENINGITIS, 

Tubercular  leptomeningitis,  basilar  meningitis,  acute  hydroceph- 
alus, is  a  local  manifestation  of  the  action  of  Koch's  bacillus,  usually 
most  intense  at  the  base  of  the  brain,  commonly  attended  by  distention 
of  the  ventricles,  almost  invariably  if  not  always  secondary,  and  practi- 
cally always  fatal. 

Etiolog-y. — The  pathological  process  in  this  form  of  meningitis  is 
clear  and  definite.  The  bacillus  of  tuberculosis  carried  to  the  meninges 
of  the  brain  by  the  vascular  system  finds  in  the  pial  fluid  and  the  perivas- 
cular spaces  a  suitable  pabulum  and  an  excellent  breeding  ground.  In  the 
great  majority  of  cases  a  primary  focus  of  tubercular  infection  is  found  in 
other  organs.  The  absolute  exclusion  of  such  original  disease  is  practi- 
cally impossible  in  the  few  remaining  cases  where  it  is  not  readily  discov- 
ered. It  has  been  suggested  that  infection  might  reach  the  cranial  contents 
by  way  of  the  nasal  vault  and  cribriform  openings.  This  can  not  be  denied, 
but  seems  improbable  and  lacks  confirmation.  Though  tubercular  infec- 
tion of  the  soft  brain-coverings  may  occur  at  any  age,  the  years  of  life 
between  two  and  ten  show  an  overwhelming  proportion  thus  affected. 
Before  the  age  of  six  months  and  in  advanced  years  it  is  practically 
unknown.  It  gradually  diminishes  after  the  age  of  ten  and  is  infre- 
quent after  thirty-five.  The  other  etiological  factors  are  those  that  are 
common  to  all  tubercular  processes.  Heredity,  both  tubercular  and 
neurotic,  has  a  significance.  Urban  populations,  conditions  of  crowd- 
ing, winter  and  spring  (the  seasons  of  exposure  and  poor  ventilation), 
depressing  influences,  deprivation,  and  tubercular  contamination  are  in- 
cluded in  the  list  of  predisposing  and  exciting  causes.  Traumatism 
m:ay  induce  a  tubercular  meningitis  perhaps  by  reducing  the  resistive 
factor  in  the  tissues  that  stays  the  bacillary  invasion.  At  any  rate,  it 
is  a  common  observation  that  spinal  and  head  injuries  in  themselves 
rather  trifling,  are  followed  by  the  disease  in  numerous  instances. 

Pathological  Anatomy. — Upon  opening  the  skull  and  reflecting 
the  dura,  hardly  any  inflammatory  action  is,  as  a  rule,  to  be  seen. 
The  arachnopia  is  sometimes  a  little  lacking  in  luster  along  the  course 


90  DISEASES  OF  THE  CEREBRAL  MENINGES. 

of  the  main  cerebral  arteries.  At  the  base,  however,  the  morbid  picture 
is  comparatively  uniform  and  striking.  At  the  arterial  circle  of  Willis, 
extending  along  the  basilar  furrows,  between  the  peduncles  and  the 
pons,  covering  the  interpeduncular  space,  and  especially  marked  in  the 
Sylv^ian  fissures,  is  a  thick,  almost  gummy  exudate,  dotted  with  small 
masses  of  a  dirty  whitish  color.  These  are  tubercles  in  various  stages  of 
development  or  degeneration.  They  frequently  dot  the  pia  on  the  lateral 
aspects  of  the  brain  and  sometimes  reach  to  the  vertex.  They  are 
always  grouped  near  the  blood-channels  and  vascular  spaces,  through 
which  evidently  the  infecting  organism  reaches  the  meninges. 

The  exudate,  often  of  a  clear,  jelly-like  consistence,  is  frequently 
turbid,  grayish-yellow,  and  not  rarely  purulent  or  even  greenish.  It  is 
found  in  greatest  quantities  at  the  base,  but  ascends  with  the  cerebral 
vessels  along  the  pial  spaces,  filling  the  sulci  and  interlobular  grooves. 
It  travels  down  the  perivascular  sheaths  into  the  cortical  substance,  and 
invades  the  ventricles  through  the  transverse  fissure.  The  inflammation 
is  here  propagated  to  the  ventricular  ependymal  lining,  resulting  in  a 
great  increase  of  fluid,  with  dilatation  of  the  ventricles  and  a  condition 
which  early  gave  to  this  disease  the  distinctive  name  of  acute  hydro- 
cephalus. This  feature  is  seldom  wanting  and  may,  by  pressure,  cause 
marked  flattening  of  the  convolutions. 

The  granular  tubercles,  usually  visible  at  a  glance,  sometimes  require 
a  little  search.  If  the  pia  be  stripped  off  and  floated  in  a  little  clear 
water,  the  tubercles  can  be  much  more  readily  distinguished.  They  are 
grouped  about  the  arterioles  or  disseminated  along  the  larger  vessels  in 
patches  and  small  masses,  which  may  rarely  unite  to  form  a  continuous 
covering  for  wide  areas  of  the  brain-surface.  They  present  the  variations 
which  mark  tubercles  elsewhere,  depending  upon  their  age  and  develop- 
ment or  disintegration.  Microscopically,  they  are  often  found  to  occlude 
the  perivascular  spaces,  giving  rise  at  times  to  small  softenings  and 
hemorrhages,  which  occasionally  attain  sufficient  proportions  to  explain 
the  focal  symptoms  that  may  have  been  clinically  manifest.  These 
infarcts  are  usually  found  in  the  basal  ganglia  and  the  cerebral  peduncles. 
The  perivascular  extension  of  the  inflammation  determines  more  or  less 
cerebrith,  and  when  the  pia  is  removed  it  often  decorticates  the  brain  in 
consequence  of  the  soft  adhesions  that  have  formed.  Infrequently  there 
are  slight  adhesions  between  the  pia  and  dura. 

In  a  large  proportion  of  cases  of  tubercular  meningitis  the  spinal  cord 
is  also  invaded.  The  meninges,  meningeal  vessels,  and  the  cord  itself 
present  features  analogous  to  those  found  within  the  cranium.  The  exu- 
date is  most  marked  in  the  anterior  and  posterior  grooves  of  the  cord, 
and  the  meningeal  changes  are  always  greater  on  the  dorsal  surface. 

Tubercular  meningitis  presents  varieties  in  which  the  pathological  find- 
ings are  most  marked  at  the  vertex.  This  is  so  rare  that  the  disease 
was  formerly  known  and  described  simply  as  basilar  meningitis.  Occa- 
sionally a  circumscribed  tubercle  or  a  tubercular  mass  gives  rise  to 
symptoms  of,  and  constitutes,  an  intracranial  tumor.  Again,  the  men- 
ingeal involvement  is  only  a  part  of  disseminated  miliary  tuberculosis, 
appearing  at  once  in  the  head,  lungs,  intestines,  peritoneum,  and  abdo- 


TUBERCULAR  MENINGITIS.  91 

minal  parenchymatous  organs.  In  these  cases,  while  all  the  pial  struc- 
tures are  the  seat  of  granular  tubercles,  they  are  most  profuse  along  the 
vascular  routes.  Ordinarily,  they  are  not  attended  with  much  exuda- 
tion and  brain  symptoms  may  be  quite  lacking  during  life. 

Baderiologically  the  tubercle  bacillus  of  Koch  is  always  found,  and 
usually  is  present  alone.  Secondary  mixed  infections  are  extremely 
rare  and  purely  adventitious.  A  case  has  been  met  in  which  the 
pneumococcus  was  also  present.  Primary  tubercular  j)rocesses  in  other 
organs,  as  in  the  serous  sacs,  the  lungs,  the  intestines,  the  mesentery,  the 
mediastinum,  or  the  genito-urinary  tract,  are  commonly  found.  A  single 
caseous  mediastinal  gland  has  served  as  the  starting-point  for  the  me- 
ningeal infection. 

Symptoms. — The  onset  of  tubercular  meningitis  is  insidious  and  its 
course  protracted.  Cases,  however,  manifest  wide  variations.  The  typi- 
cal cases  occur  in  childhood.  Those  occurring  later  in  life  are  usually 
preceded  by  well-marked  tubercular  disease  to  which  the  meningeal  com- 
plication is  added  in  a  natural  order.  Children,  on  the  other  hand,  fre- 
quently present  an  antecedent  appearance  of  good  health,  the  primary 
focus  of  disease  having  been  so  insignificant  as  to  produce  no  notable 
symptoms.  They  become  peevish,  fretful,  and  out  of  sorts.  Appetite 
and  sleep  are  disturbed.  After  a  week  or  two  of  prodromal  malaise 
with  perhaps  a  little  headache,  an  occasional  vomiting  spell,  and  slight 
febrile  disturbance,  they  are  noticed  to  be  apathetic,  then  distinctly 
drowsy,  and  later  stuporous.  If  disturbed,  they  complain  of  head- 
ache or  manifest  discomfort  and  may  vomit.  The  triad  of  symptoms — 
headache,  vomiting,  and  oonsti-pation — following  a  more  or  less  protracted 
period  of  malaise,  which  may  rarely  extend  over  months,  marked  by 
general  physical  deterioration  and  often  by  great  loss  of  flesh,  has  serious 
significance.  The  stuporous  repose  is  often  pierced,  but  not  broken,  by 
a  sharp  cry  of  pain,  the  hydrocephalic  cry,  which  in  some  cases  is  fre- 
quent and  distressing.  It  is  apparently  due  to  the  head-pain.  There  is 
retraction  of  the  head  with  more  or  less  rigidity  of  the  neck,  and  the 
entire  spine  may  be  fixed.  Slight  opisthotonos  is  common.  The  thighs 
are  flexed  on  the  trunk,  the  legs  on  the  thighs,  the  abdomen  becomes  more 
and  more  retracted,  and  finally  presents  the  scaphoid  or  boat-shaped  hol- 
lowing that  is  classical.  The  masticatory  muscles  sometimes  are  simi- 
larly stiffened,  and  the  Kernig  symptom  of  rigidity  of  the  knee  when  the 
hip-joints  are  flexed  is  usually  present. 

The  tendon-reflexes,  sometimes  indistinct,  are  often  increased  at  first 
and  gradually  diminish  as  the  depression  and  stupor  develop.  The  vom^- 
iting  continues  at  intervals  and  is  of  the  cerebral  type,  unattended  by 
evidence  of  gastric  disturbance.  The  temperature,  though  fickle,  usually 
shows  an  evening  elevation.  It  is  rarely  extremely  high  until  the  fatal 
termination  of  the  disease,  when  it  attains  103°  to  105°  F.,  or  even 
more,  but  from  101°  to  102.5°  is  frequently  seen.  Occasionally  it 
drops  below  the  normal  and  may  show  considerable  variation  in  the 
course  of  an  hour. 

The  respiration  is  not  notably  disturbed  until  stuporous  or  comatose 
conditions   obtain,  when   it   is   irregular,    sighing,   slowed,   and   of  the 


92  DISEASES  OF  THE  CEREBRAL  MENINGES. 

Chevne-Stokes  variety ;  but  Simon  ^  asserts  that  from  the  first  there  is 
a  lack  of  harmony  in  the  respiratory  movements  of  chest  and  diaphragm. 
The  jndse  then  becomes  much  altered.  It  is  slowed,  often  irregular,  and 
just  before  death  becomes  uncountably  frequent.  It  is  in  tubercular 
meningitis  especially  that  the  dissociation  of  pulse,  temperature,  and 
respiration  is  found.  Its  diagnostic  value  is  great.  Thus,  when  the 
temperature  exceeds  100°,  the  pulse  may  show  a  subnormal  rate,  and 
the  respiration  be  slow  or  rapid. 

As  the  lesion  is  usually  basilar,  involvement  of  cranial  nerves  is  the 
rule.  Sight  is  often  dimmed,  and  the  ophthalmoscope  demonstrates 
changes  in  the  fundus-picture  in  a  majority  of  cases.  Simple  hyper- 
emia, marked  congestion,  and  papillitis  may  be  expected.  Of  pathogno- 
monic importance  is  the  not  infrequent  presence  of  tubercles  in  the 
retinal  or  choroid  tunics.  Very  early  there  is  disturbance  of  the  third 
nerve  in  the  form  of  pupillary  inactivity  and  a  tendency  to  miosis,  which 
later  gives  way  to  wide  dilatation.  Strabismic  deviations  of  the  eyes,  or 
fixity  of  the  globes,  should  be  carefully  sought  for.  In  older  patients 
diplopia  is  frequently  noted.  A  strong  convergent  upward  squint, 
drawing  the  pupils  almost  to  the  inner  canthus  and  turning  the  globes 
well  up  is  usual  in  deep  coma.  The  facial  nerve  is  rather  frequently 
affected  with  a  corresponding  paretic  condition  of  the  face.  Deviation 
of  the  tongue,  pharyngeal  and  laryngeal  distress,  mark  the  implication 
of  the  posterior  members  of  the  cranial  group.  The  mental  state,  aside 
from  the  stupor,  is  one  of  confusion,  often  marked  by  moderate  delirium. 
When  the  patient  is  roused  or  is  able  to  respond  he  resents  all  inter- 
ference. Rapid  emaciation  attends  the  progress  of  the  disease.  Sphinc- 
teric  control  is  not  often  disturbed,  except  that  in  the  comatose  state  the 
bladder  and  bowels  act  automatically,  and  their  contents  are  uncon- 
sciously voided  under  the  patient.  Retention  of  urine,  however,  is 
sometimes  noted  and  persistent ;  obstinate  constipation  is  the  rule  unless 
intestinal  tuberculosis  causes  diarrheal  discharges. 

Vasomotor  disturbances  are  manifest  in  flushes  and  pallor,  which 
frequently  succeed  each  other  rapidly  or  appear  side  by  side  on  face 
and  trunk  in  peculiar  distribution.  The  tache  cerebrate  is  present.  The 
persistence  and  intensity  of  the  streaks  on  the  skin  and  the  ease  w^ith 
which  they  are  produced  give  some  significance  to  a  phenomenon  ob- 
served in  many  unallied  conditions. 

Convulsions  sometimes  open  the  sequence  of  acute  manifestations,  but 
more  often  appear  later ;  very  rarely  are  they  entirely  absent.  Due  in  large 
part  to  the  irritation  of  the  bulbar  region,  they  are  usually  generalized 
and  protracted.  Convulsive  twitchings,  especially  in  the  face  and  hands, 
indicate  the  extension  of  the  irritation  onto  the  lateral  aspects  of  the 
brain.  By  localized  disturbances  in  the  motor  cortex,  spasm  of  a  Jack- 
sonian  variety  may  be  induced.  Similarly  paresis  is  often  found,  Avhich 
may  be  localized.  In  cases  of  protracted  onset,  some  wavering  in  the 
gait,  or  even  marked  staggering  and  clumsiness,  are  of  the  same  signifi- 
cance. 

After  a  variable,  active  period  of  a  few  days,  a  week,  or  even  longer, 
1  "  La  France  Med.,"  March  29,  1895. 


TUBERCULAR  BIENINGITIS.  93 

a  marked  remission  of  the  stupor,  convulsions,  vomiting,  and  other  sit^ns 
of  active  disease  is  usually  noted.  It  is  frequently 'followed  by  a  period 
of  vacillating  improvement  that  only  too  often  gives  false  hope  and  ill- 
founded  security.  After  a  number  of  oscillations,  in  some  of  which 
the  patient  may  seem  to  touch  the  border-land  of  complete  relief,  the 
disease  again  takes  up  its  course  to  a  fatal  termination.  All  the  symp- 
toms of  depression  reappear,  the  coma  intensifies,  the  pressure  indica- 
tions increase,  the  temperature  runs  up,,  stertor  comes  on,  the  pulse  is 
inordinately  accelerated,  and  death  from  respiratory  or  cardiac  failure 
closes  the  scene,  often  attended  by  convulsions  due,  perhaps,  to  the 
asphyxiated  blood  state.  Spinal  symptoms  are  common.  The  rigidity 
of  the  back  and  lower  extremities,  and  great  tenderness  along  the  spine 
and  over  the  skin,  indicate  spinal  involvement ;  but  the  overwhelming 
cerebral  side  of  the  disease  usually  obscures  the  less  strongly  marked 
features  of  cordal  extension. 

Course. — A  disease  marked  by  such  pronounced  variations  of 
intensity,  and  even  of  localization,  necessarily  presents  a  lack  of  uni- 
formity in  its  course  and  duration.  Most  frequently  it  is  subacute. 
Rare  cases  reach  a  fatal  termination  in  a  week  or  ten  days  after  the 
onset  of  marked  symptoms.  On  the  other  hand,  the  prodromal  stage 
may  extend  over  weeks  and  months,  with  remissions  of  all  symptoms  at 
intervals.  Again,  the  mid-period,  marked  by  fluctuation,  may  protract 
the  disease  for  days  and  weeks.  Ordinarily,  the  malady  presents  four 
fairly  marked  clinical  stages  :  (1)  The  prodromal  period,  of  indefinite 
length ;  (2)  the  period  of  irritation  and  excitement,  varying  from  a  few 
days  to  a  week ;  (3)  the  period  of  oscillation,  lasting  about  as  long,  and, 
finally,  (4)  the  period  of  marked  depression,  attended  by  paralytic 
features,  deepening  coma,  and  death.  This  refers  principally  to  the 
disease  as  it  occurs  in  childhood.  In  adults  it  is  likely  to  run  a  more 
varied  and  protracted  course,  and  in  the  rare  senile  cases  it  often  pro- 
vokes but  insignificant  disturbances. 

The  diagnosis  is  avowedly  difficult.  In  the  prodromal  period  it  is 
never  positive.  When  drowsiness,  headache,  vomiting,  and  constipa- 
tion are  found  following  a  week  or  more  of  malaise  and  petulance,  the 
meningeal  character  of  the  trouble  would  be  pertinently  suggested. 
The  detection  of  a  primary  tubercular  process,  or  of  tubercles  in  the 
retina,  is  a  practical  confirmation  of  the  diagnosis.  Strong  hereditary 
tendency  to  tuberculosis,  and  more  emphatically  a  family  history  of 
several  cases  of  tubercular  meningitis,  would  raise  a  strong  presump- 
tion, when  attended  by  the  cerebral  triad,  headache,  vomiting,  and  con- 
stipation, that  tubercular  meningeal  infection  had  taken  place.  Con- 
tinued exposure  to  tubercular  infection  has  some  significance.  The 
differential  diagnosis  from  acute  meningitis  depends  principally  on  the 
subacute  onset  and  lower  grade  of  intensity  of  all  the  symptoms  in  the 
tubercular  variety.  This  is  manifestly  indefinite,  and  clinically  the  two 
forms  of  meningitis  can  not  always  be  distinguished.  Quincke's  punc- 
ture furnishes  a  practical  test.  The  bacillus  tuberculosis  is  found  in 
the  spinal  fluid  in  about  four-fifths  of  the  tubercular  cases.     In  other 


94  DISEASES  OF  THE  CEREBRAL  MENINGES. 

cases  the  presence  of  the  pneumococcus  or  of  pus  has  made  a  differen- 
tial diagnosis  possible. 

Prognosis. — Practically  the  only  hopeful  point  in  prognosis  is  the 
possibility  of  a  mistaken  diagnosis.  A  few  undoubted  cases  of  tuber- 
cular meningitis  have  recovered,  and  the  post-tubercular  lesion  has  been 
found  after  death  from  subsequent  and  unrelated  causes.  Dr.  G.  Fut- 
terer,  ^  formerly  assistant  to  Rindfleisch,  relates  a  case  in  which  tubercu- 
lar meningitis  had  been  diagnosed  by  Prof.  Leube.  Five  years  later 
calcareous  tubercles  were  found  in  the  spinal  meninges.  Henoch, 
Pollitzer,  and  Freyhan  also  report  cases  that  have  a  similar  bearing. 
Their  extreme  rarity  hardly  invalidates  the  rule  of  fatality.  Owing, 
in  some  cases,  to  the  difficulty  of  a  differential  diagnosis,  the  physician 
should  always  maintain  a  margin  of  reserve.  This  is  particularly 
important  in  the  oscillatory  period  of  the  disease,  when  apparent  recovery 
may  be  most  deceptive. 

Treatment. — The  same  general  management  and  care  should  be 
employed  as  in  acute  meningitis.  Actuated  by  the  beneficial  results  of 
iodoform  injections  in  tubercular  joint-disease,  in  Germany  inunctions 
of  the  shaven  scalp  with  the  same  medicament  have  been  warmly  advo- 
cated. They  may  be  tried.  All  are  united  on  the  use  of  calomel  in 
small  repeated  doses.  The  mercurial  not  only  is  the  best  agent  against 
the  constipation,  but  may  have  some  effect  upon  the  inflammatory  process 
within  the  skull.  The  extreme  tendency  to  rapid  emaciation  suggests 
the  most  careful  and  persistent  efforts  to  maintain  the  nutrition  by  every 
jDOSsible  means.  When  the  stomach  is  intolerant,  rectal  alimentation 
may  be  employed  and  cod-liver  oil  inunctions  are  useful.  Digestion  can 
sometimes  be  assisted  by  peptonizing  and  predigesting  the  food.  Stim- 
ulation by  whisky  or  a  good  wine  is  important  in  the  later  stages. 
During  the  period  of  excitement  sedatives  are  required.  In  children 
the  bromid  of  potassium  is  a  useful  remedy.  It  frequently  controls 
the  headache  and  reduces  the  convulsive  tendency.  The  action 
of  the  potassium  salt  in  producing  arterial  contraction  is  increased 
by  the  addition  of  chloral,  which  may  be  profitably  combined  with 
it.  Applications  of  ice  or  the  cold  coil  to  the  head  seem  at  times  to 
give  some  comfort  and  relief  from  pain.  Antipyretics,  aside  from  fre- 
quent gentle  sponging,  are  rarely  indicated  and  usually  do  no  good. 
The  hot  bath  often  effectually  controls  the  convulsions.  Of  late  the  value 
of  drainage  or  mere  exploration  of  the  peritoneum  in  tubercular  infec- 
tion of  that  cavity  has  turned  attention  to  the  possible  value  of  a  similar 
procedure  in  tubercular  meningitis.  Some  of  these  cases  have  been 
drained  and  the  ventricles  tapped  with  alleged  temporary  improvement. 
Quincke's  lumbar  puncture,  which  certainly  reduces  intracranial  pressure 
and  removes  the  fluid,  has,  in  the  cases  reported  by  Strahan,  been  fol- 
lowed by  recovery  once.  As  a  fatal  ending  is  the  only  reasonable  expec- 
tation, when  the  diagnosis  has  been  confirmed  by  the  lumbar  puncture, 
the  injection  of  iodoform  emulsions  or  other  solutions  within  the  spinal 
and  cranial  dura  may  be  attempted  with  propriety. 

1  ' '  Chicago  Medical  Recorder, ' '  June,  1895. 


DISEASES  OF  THE  FIRST  AND  SECOND  CRANIAL  NERVES.  95 


CHAPTER  IV. 

DISEASES  OF  THE  FIRST  AND  SECOND  CRANIAL 

NERVES. 

Diseases  of  cranial  nerves  are  broadly  divided  into  those  which  affect 
the  GOfiical  centers,  those  which  involve  the  nuclei,  and  those  which 
involve  trunks  and  peripheral  portions.  The  peripheral  nerves  extend 
from  the  nuclei  to  the  ultimate  distribution  of  their  fibers.  A  part  of 
their  course  lies  within  the  mass  of  the  brain  itself.  While  the  peripheral 
portion  of  a  cranial  nerve  may  suffer  independently  of  its  nucleus,  injury 
to  the  nuclear  center  is  always  followed  by  degeneration  in  the  periph- 
eral part.  It  is  not  unusual  for  a  peripheral  nerve  to  be  singly  injured 
by  traumatism,  or  even  by  disease,  but,  owing  to  the  close  anatomical  and 
physiological  relations  of  the  cranial  nuclei,  the  medullary  centers  are 
rarely  individually  diseased.  Very  often  nuclear  disease  of  the  cranial 
nerves  is  but  a  portion  of  a  more  general  nervous  malady.  The  suc- 
cessive nuclear  centers  in  the  medulla,  along  the  floor  of  the  fourth 
ventricle,  under  the  aqueduct  of  Sylvius,  and  on  the  posterior  wall  of  the 
third  ventricle,  constitute  the  upward  prolongation  of  the  spinal  gray 
matter.  They  may  be  involved  with  the  spinal  centers  at  the  same 
period  or  at  varying  stages  of  a  given  general  malady.  The  peripheral 
parts  of  the  cranial  nerves  also  participate  in  the  general  diseases  which 
affect  the  spinal  nerves  and  react  similarly  to  infections  and  poisons. 
The  analogy  of  the  last  ten  cranial  pairs  to  the  spinal  nerves  should  be 
clearly  apprehended.  The  olfactory  and  optic  nerves  react  more,  as 
does  the  brain  proper.  They  are,  in  fact,  portions  or  lobes  of  the  brain. 
To  a  less  degree  the  same  is  true  of  the  auditory  nerve. 

Diseases  of  the  Olfactory  Kerve. — The  exact  cortical  origin  of 
the  olfactory  nerve  is  not  known.  Its  pathway  in  the  brain  is  not 
clearly  traced.  Its  disturbance,  usually  considered  of  slight  importance, 
is  often  overlooked.  Ordinarily,  the  olfactory  cortical  center  is  assigned 
to  the  uncinate  gyrus,  or  near  by,  in  the  cornu  ammonis  in  the  floor  of 
the  lateral  ventricle.  ^  Certain  cases  of  epilepsy  in  which  an  aura 
referable  to  the  sense  of  smell  was  noted  have  presented  post-mortem 
evidences  of  disease  of  the  temporosphenoidal  lobe  near  to  or  involving 
the  uncinate  convolution.  The  same  is  true  of  some  cases  of  mental 
disease  marked  by  hallucination  of  smell.  It  seems  probable  that  the 
olfactory  nerve  is  represented  on  both  sides  of  the  brain. 

A  loss  of  smell  on  the  side  opposite  to  a  lesion  in  the  posterior  por- 
tion of  the  internal  capsule  has  been  noted  by  F6r6  ^  and  confirmed  by 
others.  Usually,  however,  the  lesion  is  on  the  same  side  of  the  brain, 
and  involves  the  olfactory  tract,  the  bulb,  or  the  nervous  filaments, 
which  are  distributed  to  the  nasal  vault  through  the  cribriform  plate  of 

^  Zuckerkandl,  "  Ueber  das  Riechscentrum."  ^  "Arch,  de  Neurologic,"  1885. 


96  DISEASES  OF  THE  CRANIAL  NERVES. 

the  ethmoid.  Disease  of  the  middle  cerebral  artery  near  its  origin  from 
the  circle  of  Willis  may  cause  loss  of  smell  in  the  corresponding  nos- 
tril. This  is  probably  through  injury  to  the  brachia  of  the  olfactory 
tract.  Basilar  fracture  often  destroys  the  nerve  at  the  cribriform  plate. 
In  such  cases  the  loss  of  smell  is  an  important  localizing  fact.  Local- 
ized meningitis,  caries  of  bone,  tumors,  or  abscesses  may  have  the  same 
effect.  Hydrocephalus  may  seriously  compress  these  nerves.  It  has 
been  claimed  that  tumors  situated  in  distant  parts  of  the  brain  provoke 
neuritis  in  the  olfactory  tract  similar  to  the  optic  neuritis  usually  asso- 
ciated with  encephalic  neoplasms.  In  old  age  the  olfactory  bulb  atrophies 
and  the  sense  of  smell  diminishes.  In  hysteria  smell  may  be  entirely  abol- 
ished. This  may  be  a  bilateral  condition  and  exist  practically  alone, 
but  is  usually  unilateral  and  confined  to  the  hemianesthetic  side  of  the 
body.  Gowers  mentions  some  cases  in  which  the  recognition  of  certain 
odors  alone  was  lost.  Overstimulation  of  the  sense  of  smell  will  para- 
lyze it,  and  the  loss  may  be  permanent.  Ordinarily,  a  strong  stimulation 
for  three  or  four  minutes  so  blunts  the  sense  that  it  no  longer  recognizes 
the  particular  odor,  but  recovers  itself  in  about  a  minute.  Continued 
exposure  to  strong  odors  usually  result  in  permanently  diminishing  this 
special  sense.  Oversensitiveness  is  occasionally  noted  in  neurotics,  and 
can  be  cultivated.  The  blind  and  those  who  taste  tea  or  inspect  certain 
articles  of  commerce  gain  great  sensitiveness  in  this  way.  Finally,  the 
olfactory  bulb  may  be  congenitally  wanting. 

The  prognosis  in  loss  of  smell  from  disease  of  the  olfactory  nerve  is 
usually  bad.  It  depends  on  the  cause  in  a  given  case.  Catarrhal  nasal 
conditions,  fifth-nerve  disturbance,  and  hysteria  must  be  ruled  out.  The 
use  of  faradism  is  said  to  have  done  good  in  a  few  cases.  It  is  applied 
to  the  mucous  expanse  over  the  turbinates,  and  is  very  painful.  Snuffs 
containing  strychnin  or  quinin  may  be  tried.  Oversensitiveness  is  con- 
trolled by  morphin  or  cocain,  but  their  use  is  attended  by  the  danger 
of  setting  up  an  incorrigible  habit. 

Diseases  of  the  Optic  Nerve. — The  Visual  Tract. — Only  the 
infinitely  short  fibers  between  the  layer  of  rods  and  cones  and  the  retinal 
nerve-cells  can  properly  be  called  peripheral  optic  nerves.  The  retro- 
ocular  bundles  that  are  named  optic  nerves  by  anatomists  react  to 
injury,  as  do  other  cerebral  connecting  tracts.  Like  them,  if  divided 
they  never  unite,  while  peripheral  nerves  unite  readily  under  proper 
conditions. 

The  term  optic  nerve,  with  this  understanding,  will,  however,  be 
used  as  ordinarily  accepted.  The  retina  is  made  up  of  two  lateral 
halves  supplied  from  corresponding  sides  of  the  brain, — that  is  to  say, 
the  right  half  of  each  retina  is  in  anatomical  connection  with  the 
right  cerebral  hemisphere  and  the  left  half  of  each  retina  with  the  left 
hemisphere.  At  the  macula  lutea,  or  point  of  greatest  visual  activity, 
these  halves  overlap.  This  central  part  of  the  retina  is  thereby  abun- 
dantly supplied  from  both  hemispheres.  As  the  bridge  of  the  nose  cuts 
off  much  light  that  would  enter  the  pupil  from  that  direction,  the  temporal 
or  outer  halves  of  the  retinae  are  rendered  in  part  functionally  inactive 
and  their  afferent  fibers  are  less  in  number.      The  optic  nerve  in  conse- 


DISEASES  OF  THE  FIBST  AND  SECOND  CRANIAL  NERVES. 


97 


quence  contains  many  more  fibers  for  the  inner  tlian  for  the  outer  halves 
of  the  eye-grounds. 

At  the  chiasm  in  man  a  partial  decussation  takes  place.     The  larger 
number  of  fibers,  those  in  relation  with  the  inner  or  nasal  halves  of  the 
retinae,  cross  to  the  opposite  side.     Those   from  the  temporal  halves  of 
the  retinae  pass  backward  on  the  same  side.     At  this  point  a  number  of 
fibers  enter  the  gray  matter  in  the  floor  of  the  thii'd  ventricle.      Back 
of  the  chiasm  the  temporal  fibers  of  the  right  eye  are  accompanied  by 
the  nasal  fibers  of  the  left  eye,  and  they  together  make  up  the  right  optic 
tract.      In  other  ^Yords,  the  right  optic  tract  contains  all  the  fibers  going 
to  the  right  halves  of  both  eyeballs.      It  is,  then,  clear  that  while  division 
of    an    optic    nerve    causes 
absolute    blindness    of    one 
eye,    division   of   one   optic 
tract   would    produce   half- 
blindness  of  the  correspond- 
ing   sides   of    both    retinse. 
This  would  manifest  itself 
in  blindness  in  the  opposite 
halves  of  the  visual  fields, 
heimanopsia,   owing  to    the 
fact  that    oblique    rays    of 
light  entering  the  pupil  im- 
pinge on  the  opposed  por- 
tion of  the  retina.    A  glance 
at  figure  29  will  make  this 
clear.      Owing  to  the  fact 
that  the  macula  has  a  dou- 
ble supply,  the  hemianopsic 
field  always   shows    an   in- 
denture at  the  fixing  point. 
In  such  cases  direct  vision 
may    not    be    impaired    in 
acuity,  so  thoroughly  is  each 
macula    supplied    by    both 
hemispheres.    The  dividing 
line  between  the  half-fields 
in  a  hemianopsic  eye  is  prac- 
tically vertical,  but  may  incline  one  way  or  the  other  to  a  slight  extent 
in  various  individuals. 

Injury  dividing  the  chiasm  longitudinally  would  cut  off  all  the 
fibers  to  both  nasal  halves  of  the  retime  and  produce  double  hemianopsia, 
marked  by  blindness  for  all  objects  to  the  right  for  the  right  eye  and  all 
objects  to  the  left  for  the  left  eye.  Enlargement  of  the  pituitary  gland 
or  pressure  through  the  floor  of  the  third  ventricle  may  cause  this 
result. 

A  lesion  cutting  off"  the  direct   fibers  on  the  lateral  margin  of  the 
chiasm  would  produce  blindness  of  the  temporal  half  of  the  retina  on 
the  same  side.      In  extremely  rare  instances  a  bilateral  blindness  in  the 
7 


Fig.  29.— Diagram  of  visual  path.s  (after  Starr). 


98  DISEASES  OF  THE  CR AXIAL  NERVES. 

nasal  fields  is  caused  by  symmetrical  lesions  in  this  locality,  as  by  cal- 
careous carotids. 

The   optic  tract  passing  backward  encircles  the  crus  cerebri    and 
enters   the  geniculate   bodies,  the   anterior  corpus  quadrigeminum,  and 


Left.  Eight. 

Fig.  30. — Blindness  in  both  temporal  fields  in  a  case  of  acromegalia  due  to  injury  of  the  chiasm  by 
pituitary  enlargement.    The  nasal  fields  are  also  contracted. 

the  optic  thalamus  of  the  same  side.  From  these  ganglionic  bodies 
fibers  then  pass  outward  and  backward  around  the  posterior  horn  of 
the  lateral  ventricle,  to  end  in  the  cortex  of  the  cuneus,  the  postero- 
internal portion  of  the  occipital  lobe.  This  portion  of  the  occipital  lobe 
represents,  therefore,  half-vision  for  each  eye  and  is  in  relation  with  the 


Left.  Right. 

Fig.  .31.— Homonymous  lateral  hemianopsia  from  an  injury  to  the  right  occipital  apex.     The  right 
lateral  fields  also  contracted. 

lateral  halves  of  the  retinae  on  the  same  side  of  each  eyeball.  Any 
lesion  that  interrupts  the  visual  pathway  back  of  the  chiasm,  or  destroys 
the  visual  centers  in  the  cuneus,  produces  lateral  homonymous  hemi- 
anopsia. 


DISEASES  OF  THE  FIRST  AND  SECOND  CRANIAL  NERVES.  99 

The  cortical  half-vision  centers  of  the  cuneus  are  in  turn  brought  by 
connecting  fibers  into  relation  with  higher  centers  for  visual  memories, 
probably  situated  in  and  about  the  angular  gyri  of  the  parietal  lobes. 
In  these  higher  visual  centers  both  eyes  are  represented  in  each  hemi- 
sphere. The  parietal  centers  probably  freely  communicate  through  the 
callosal  crossway.  Injury  to  the  left  parietal  region  in  right-handed 
persons  produces  loss  of  visual  word-memories,  or  tvor el-blindness,  but 
does  not  cause  hemianopsia. 

The  fibers  which  supply  the  macula  lutea  of  the  retina  occupy  at  the 
apex  of  the  orbit  the  central  portion  of  the  optic  nerve  in  close  proxim- 
ity to  the  central  artery  and  vein.  They  then  become  superficial  on  the 
outer  side  of  the  nerve  and  proceed  in  this  position  to  the  back  of  the 
eye.  Aneurysm  of  the  central  artery  or  axillary  inflammation  of  the 
nerve  about  the  artery  may  so  involve  them  that  blindness  of  the  center 
of  the  field  develops.     This  condition  of  central  blindness,  or  central 


Left.  Right. 

Fig.  32. — Scotomata  in  toxic  amblyopia,  consisting  of  increased  size  of  blind  spots,  which  are  represented 

by  the  darker  shading. 

scotoma,  is  also  common  in  tobacco  and  alcoholic  amblyopia.  The  poison 
seems  to  have  the  greatest  effect  on  the  most  used  and  consequently  most 
sensitive  fibers  or  their  related  parts. 

The  loss  of  vision  is  sometimes  limited  to  a  quadrant  of  the  field. 
The  quadrant  in  the  field  is  bounded  practically  by  lines  horizontal  and 
vertical  to  the  fixing  point,  which  itself  is  spared.  A  case  originally 
presenting  hemianopsia  may  eventually  recover  in  part  and  a  quadrantic 
loss  alone  remain.  It  is  probable  that  these  quadrants  are  specially 
represented  in  the  occipital  cortex.  In  organic  hemianopsia  usually  the 
seeing  half  of  the  field  is  also  more  or  less  peripherally  reduced.  The 
blind  portion  of  the  field  may  not  be  uniformly  affected,  some  fractional 
vision  remaining  at  various  points.  Rarely  cases  have  been  noted  in 
which  there  was  hemianopsia  for  certain  colors  alone.  In  tobacco  blind- 
ness the  central  scotoma,  as  a  rule,  varies  for  different  colors. 

In  locating  the  lesion  that  causes  hemianopsia,  the  hemianopsic pupillary 


100 


DISEASES  OF  THE  CRANIAL  NERVES. 


reaction  of  Wernicke  is  of  value.  If  the  pupil  responds  when  a  narrow 
beam  of  light  falls  on  the  blind  retina,  the  lesion  is  back  of  the  genicu- 
late bodies.  The  presence  of  this  reaction  indicates  that  the  pupillary 
nerves  are  not  involved.  They  accompany  the  optic  tract  as  far  as  the 
geniculate  bodies.  The  test  mast  be  made  with  great  care.  The  reac- 
tion has  a  positive  significance,  when  present,  that  its  absence  lacks. 
A  double  temporal  blindness  by  itself  is  positive  evidence  of  disease  of 
the  chiasm.  When  an  optic  tract  is  involved,  the  crus  is  almost  invari- 
ably affected  at  the  same  time  by  the  same  lesion,  so  that  paralytic  body- 
symptoms  on  the  same  side  as  the  blind  field  or  opposite  to  the  blind 
retinal  half  are  present.  Other  cranial-nerve  lesions  are  likely  also  to 
be  present.  Lesions  of  the  geniculate  bodies,  the  corpora  quadrigemina, 
and  the  optic  thalami  almost  invariably  involve  the  internal  capsule  and 
produce  paralysis  in  the  body  on  the  opposite  side.  A  pure  double 
hemianopsia  may  be  produced  by  injury  to  the  cuneus. 


Left. 


Right. 


Fig.  33.- 


-Quadrantic  loss  of  visual  fields  following  meningitis.    Some  peripheral  contraction  also  present 
in  the  right  field. 


A  transient  hemianopsia  occasionally  is  a  symptom  of  migraine  and 
lithemia.  It  is  not  impossible  that  hysteria  may  produce  it,  but  concen- 
tric contraction  of  the  field  and  changes  in  the  color  formula  are  usual 
and  characteristic  in  hysteria.  In  organic  hemianopsia  the  reductions  of 
the  field  embrace  form  and  colors  equally. 

The  optic  nerve  is  often  injured  by  intra-orbital  disease,  such  as  tumor 
or  aneurysm.  It  may  be  cut  oif  at  the  foramen  opticum  by  a  basilar 
fracture,  or  involved  by  inflammation  from  caries  of  the  sphenoid.  An 
extension  of  inflammation  down  the  sheath  in  meningitis  is  not  rare. 

The  chiasm  is  injured  most  frequently  by  pituitary  tumors,  by  syph- 
ilitic growths,  and  by  pressure  from  the  third  ventricle  in  hydrocephalus. 
Gouty  changes  and  interstitial  hemorrhage  have  also  been  observed. 
Diseased  carotids  may  press  upon  it. 

The  optic  tract  may  be  involved  in  basilar  tumors  or  those  on  the  in- 
ternal aspect  of  the  temporosphenoidal  lobes.  A  patch  of  thickening 
in    multiple    sclerosis    may  aflect    it.       The    intracerebral  path  of  the 


DISEASES  OF   THE  FIRST  AND   SECOND    CRANIAL   NERVES.      101 

visual  tract  is  often  affected  by  tumors,  hemorrhage,  softening,  and 
traumatism. 

The  Papilla  and  Retina. — Associated  with  or  consequent  upon 
many  organic  processes  in  the  brain  and  spinal  cord,  the  optic-nerve  head 
and  the  retina  are  diseased.  In  two-thirds  or  more  of  the  cases  of  en- 
cephalic tumors  papillitis,  usually  double,  is  present  at  some  period.  It 
presents  ophthalmoscopically  the  choked  disc.  The  onset,  often  sudden, 
may  be  insidious,  and  in  some  measure  the  rate  of  development  is  related 
to  the  activity  of  the  new  growth.  While  a  long-standing  growth  in  the 
brain  may  give  rise  to  a  sudden  papillitis,  a  chronic  process  in  the  nerve- 
head  is  never  associated  with  acute  brain  disease.  Of  much  importance 
is  the  fact  that  a  well-marked  choked  disc  may  not  be  attended  by  much 
loss  of  vision  and  no  symptoms  may  call  the  patient's  attention  to  its 
presence.  In  some  cases  temporary  loss  of  vision,  lasting  from  a  few 
minutes  to  several  hours,  has  been  noted.  Intense  optic  neuritis  linally 
affects  vision  in  all  its  modes.  Acuity  is  diminished,  the  field  is  reduced 
for  form  and  color,  scotomata  for  both  are  frequent,  and  blindness  may  be 
induced.  The  papilla  is  swollen  and  infiltrated  with  a  plastic  material 
that  obscures  the  outline  and  enlarges  and  elevates  the  disc.  The  organ- 
ization of  the  infiltrate,  and  consequent  shrinking,  causes  the  final  dam- 
age to  the  entering  nerve-fibers.  Papillitis  may  terminate  in  recovery, 
but  its  legitimate  end  is  more  or  less  atrophy  of  the  optic  nerve  with 
impairment  of  vision  or  complete  blindness.  In  several  cases  of  brain- 
tumor  with  optic  neuritis,  the  papillitis  subsided  on  the  removal  of  the 
tumor.  Even  opening  the  skull  widely  may  cause  a  reduction  of  the 
papillitis  in  inoperable  brain  tumors  and  prevent  blindness.  In  other 
instances  improvement  in  the  brain-lesion  is  attended  by  decreasing 
papillitis.  The  intensity  of  the  papillitis,  therefore,  has  some  diagnostic 
and  prognostic  value. 

Papillitis  rarely  results  from  brain-abscess,  but  in  basilar  meningitis  a 
papillo-  or  neuroretinitis  is  extremely  frequent.  In  this  form  the  choking 
of  the  disc  is  less  marked.  Orbital  disease  is  the  usual  cause  of  unilateral 
papillitis,  but  in  rare  cases  a  one-sided  optic  neuritis  has  been  caused  by 
tumor,  generally  on  the  same  side  of  the  brain.  Wilder  ^  notes  that  in 
ten  cases  where  optic  neuritis  was  distinctly  greater  in  one  eye  than  in  the 
other,  the  tumor  was  on  the  side  of  the  brain  corresponding  to  the  more 
intense  inflammation.  Marcus  Gunn  ^  found  that  the  tumor  and  unilat- 
eral papillitis  were  located  on  the  same  side  of  the  head  in  eighteen  of 
twenty-four  cases,  and  with  greater  uniformity  in  the  tumors  that  were 
situated  anteriorly.  The  localizing  value  of  bilateral  papillitis  is  prac- 
tically negative,  as  it  is  common  to  tumors  in  all  parts  of  the  brain,  but 
is  particularly  frequent  with  cerebellar  growths  and  those  situated  in  the 
brain-axis. 

Optic  neuritis  also  occurs  in  toxemic  conditions.  It  is  sometimes 
found  in  anemia,  often  in  albuminuria  and  in  lead  poisoning,  and  after  in- 
fectious fevers.  In  the  albuminuric  form  the  retinal  expanse  is  commonly 
invaded,  but  sometimes  the  changes  are  practically  confined  to  the  disc. 

Regarding  the  causation  of  papillitis,  many  theories  have  been  adduced 
and  rejected.      In  some  cases  it  is  clearly  due  to  irritation  descending 

1  "Chicago  Medical  Eecorder,"  June,  1894.  ^  "London  Lancet,"  July,  1897. 


102 


DISEASES  OF  THE  CRANIAL  NERVES. 


the  sheath  of  the  optic  nerve  from  intracranial  inflammation.  The  idea  that 
it  is  due  to  intracranial  pressure  or  pressure  within  the  optic-nerve  sheath 
in  all  cases  has  been  abandoned.  In  toxic  cases  it  may  represent  the  local 
action  of  the  poison.  Deutschmann  ^  insists  that  it  is  due  to  pathogenic 
organisms  which  enter  from  without.      The  question  is  not  settled. 

Atrophy  of  the  optic  nerve  may  (1)  follow  papillitis  and  reti- 
nitis or  choroiditis ;  (2)  it  may  result  from  injury  or  inflammation 
to  the  nerve-trunk  ;  (3)  it  may  be  associated  Avith  sclerotic  disease  in 
the  brain  and  spinal  cord ;  (4)  it  may  be  due  to  diabetes,  malaria, 
or  syphilis ;  and  (5)  it  may  be  of  unknown  causation. 

The  atrophy  consecutive  to  papillitis  is  easily  understood,  and  of  the 
same  nature  is  the  retinitic  and  choroiditic  forms.  Injury  to  the  optic 
nerve  naturally  results  in  atrophic  degeneration  of  the  nerve-head.  That 
form  of  optic  atrophy  found  in  about  a  tenth  of  the  cases  of  locomotor 
ataxia,  often  present  in  paretic  dementia,  and  not  infrequent  in  multiple 


Fig.  34. — Optic  neurit!.* 


Fi.g.  35. — Atrophy  of  the  optic  nerve. 


or  disseminated  sclerosis,  has  an  importance  quite  its  own.  Atrophy  is 
found  in  amaurotic  idiocy  and  in  the  cerebellar  form  of  family  ataxia. 

The  symptoms  and  ophthalmoscopic  pictures  are  tolerably  uniform 
for  the  various  forms.  In  the  variety  associated  with  tabes  the  disc  is 
often  grayish,  translucent,  and  shows  the  stipling  of  the  lamina  cribrosa. 
In  the  postpapillitic  form  the  translucency  and  stipling  are  less  marked. 
In  amaurotic  idiocy  there  is  a  peculiar  bluish  spot  at  the  site  of  the 
macula  about  twice  the  size  of  the  disc,  presenting  in  its  center  a 
brownish-red  spot  strongly  contrasting  with  its  surrounding  patch  and 
resembling  a  central  embolism  or  hemorrhage.  At  the  same  time  the  disc 
is  atrophic.  In  all  forms  of  atrophy  the  disc  is  sharjily  outlined  from 
the  surrounding  retina  by  its  pallor  and  the  vessels  are  dimini.shed  in  size. 

Functional  and  Toxic  Blindness. — The  peculiarities  of  hysterical 
blindness  will  be  detailed  in  the  description  of  that  disease.  In  such  cases 
1  "Ueber  Neuritis  Optica,"  1887. 


DISEASES   OF  THE  OCULAR  NERVES.  103 

the  loss  of  vision  may  come  on  slowly  or  suddenly.  It  is  usually  uni- 
lateral and  most  marked  on  the  paralytic  or  anesthetic  side  of  the  body, 
but  the  opposite  eye  is  nearly  always  somewhat  aife(jted.  The  charac- 
teristics are  contracted  fields  and  inversion  of  the  color  formula.  When 
apparently  absolute,  by  using  prisms  or  other  suitable  means,  it  can  be 
demonstrated  that  the  eye  operates  properly,  but  that  ocular  impressions 
are  ordinarily  neglected  by  the  higher  visual  centers,  where  the  disturb- 
ance must  be  located. 

Disease  in  branches  of  the  fifth  nerve  is  sometimes  attended  by 
partial  blindness.  This  is  marked  by  considerable  concentric  contrac- 
tion of  the  field  and  some  loss  of  acuity  of  vision.  It  is  principally 
associated  with  disturbance  in  the  dental  branches,  particularly  those  to 
the  molar  teeth. 

Acute  anemia,  the  result  of  excessive  hemorrhage,  sometimes  induces 
blindness  that  may  be  complete  and  permanent. 

A  number  of  general  toxic  states,  such  as  uremia  and  syphilis,  and 
those  due  to  quinin  and  lead,  may  cause  amblyopia.  Uremic  blindness 
is  often  of  sudden  onset,  but  may  be  preceded  by  dimness  or  haziness  of 
vision.  The  fundus  in  such  cases  usually  presents  albuminuric  retinitis 
and  Bright's  disease  is  present.  Temporary  or  recurrent  blindness  in 
syphilitic  involvement  of  the  brain  is  sometimes  a  valuable  early  diag- 
nostic symptom  of  that  condition  and  also  of  brain-tumor.  Early  cor- 
rection of  the  toxic  state  in  the  various  poisonings  usually  promptly 
results  in  a  return  of  vision,  but  the  persistence  of  toxemia  may  induce 
permanent  blindness. 

Excepting  in  the  albuminuric  cases,  the  fundus  at  first  ordinarily 
presents  nothing  abnormal.  Sometimes  pupillary  symptoms  are  absent ; 
sometimes  there  is  dilatation  and  immobility.  The  difference  seems  to 
be  due  to  the  essential  involvement  of  the  cortical  cells  in  the  first  case, 
and  of  the  retinal  cells,  or  of  both,  in  the  second. 

No  attempt  is  made  in  the  foregoing  to  exhaustively  treat  of  the  dis- 
eases of  the  visual  tract  and  retina.  The  involvement  of  the  second 
cranial  nerve  is  commonly  only  a  part  of  a  neurological  case,  but  has  a 
symptomatic  value  of  great  importance.  From  this  standpoint  the  various 
features  that  relate  to  diseases  of  the  nervous  system  have  been  grouped. 


CHAPTER  V. 

DISEASES  OF  THE  OCULAR  NERVES-THE  THIRD, 
FOURTH,  AND  SIXTH  CRANIAL  PAIRS, 

Anatomical  Considerations. — The  muscles  of  the  eye  are  supplied 
l)y  the  third,  fourth,  and  sixth  cranial  pairs  and  the  sympathetic.  The 
third,  fourth,  and  sixth  nerves  arise  from  collections  of  cells  ranged  from 
before  backward,  under  the  posterior  portion  of  the  middle  ventricle,  the 
aqueduct  of  Sylvius,  and  the  anterior  angle  of  the  fourth  ventricle. 

They  have  in  common  the  function  of  controlling  the  movements  of 
the  eyeballs.      In  addition,  the  third  nerve  governs  contraction  of  the 


104 


DISEASES  OF  THE  CRANIAL  NERVES. 


WM. 


iris  and  the  ciliary  muscle,  and  elevation  of  the  upper  eyelid.  The  sym- 
pathetic, through  the  optic  ganglion,  dilates  the  pupil.  Starting  from 
before  backward  in  the  nuclei  of  the  third  nerve,  we  find  represented  (1) 
ciliary  and  then  (2)  jjupillary  contractions.  The  centers  for  the  extrinsic 
ocular  muscles  follow  presumably  in  the  following  order :  The  internal 
rectus,  the  superior  rectus,  the  elevator  of  the  eyelid,  the  inferior  rectus, 
and  the  inferior  oblique.  The  fourth  nerve  is  distributed  solely  to  the 
superior  oblique,  and  its  center  is  placed  close  behind  those  for  the  third 
nerve.  At  a  little  distance  caudad  under  the  floor  of  the  fourth  ventricle 
is  the  center  for  the  sixth  nerve,  which  controls  the  external  rectus.  All 
these  centers  are  in  close  functional  and  anatomical  relationship,  and  can 
reasonably  be  considered  as  a  single  mechanism,  made  up  of  three  por- 
tions.     The  first  is  the  iridociliary,  the  second  embraces  the  centers  for 

the  muscles  of  convergence,  and 
the  third  comprises  the  nucleus 
for  the  sixth  nerve,  which  con- 
trols the  external  rectus,  the 
only  divergent  ocular  muscle. 
Ocular  movements  are  also  rep- 
resented in  the  frontal  motor- 
cortex.  The  nuclear  centers  are 
connected  with  the  higher  levels 
through  the  motor  radiations 
and  the  internal  capsule.  The 
muscles  governed  by  the  third 
nerve  are  also  brought  into  re- 
lation with  the  orbicular  mus- 
cles of  the  lids  by  nuclear  con- 
nection with  the  facial  nerve. 
The  accommodation  and  light 
reflex  are  thereby  correlated  to 
the  act  of  winking  and  the  posi- 
tion of  the  palpebral  curtains. 
Based  upon  the  studies  of 
Schaefer,  Unverricht,  Danillo, 
Munk,  and  his  own  experi- 
ments, Roux  1  asserts  that  the  oculomotor  apparatus  has  a  double  cortical 
representation  ;  first  an  anterior  one  at  the  foot  of  the  second  frontal 
convolution,  and,  second,  a  posterior  center  in  the  occipital  region.  A"on 
Bechterew  ^  also  contends  that  irritation  of  the  anterior  margin  of  the 
occipital  lobe  in  the  dog  produces  narrowing  of  the  pupil  and  increase 
of  accommodative  eff'ort. 

The  various  ocular  muscles  serve  to  move  the  globe  in  the  orbit  in 
the  directions  indicated  by  their  names  ;  but  the  superior  and  inferior 
recti,  owing  to  the  oblique  direction  from  the  apex  of  the  orbit  to  their 
insertion,  also  draw  the  eyeball  toward  the  nose  and  rotate  it  imvard. 
This  is  counteracted  by  the  oblique  muscles  and  the  external  rectus,  but 
the  oblique  muscles  also  act  in  convergence.  Convergence  of  the  eyes, 
1  "Arch,  de  Neurol.,"  Sept.,  1899.  ^  <<  Xeurolog.  Centralblatt, "  ^l&j,  1900. 


Fig.  36. — Diagrammatic  longitudinal  section  of  the 
mid-brain,  showing  the  relation  of  the  nuclear  centers 
for  the  ocular  muscles  (aftei'  Brissaudj. 


DISEASES  OF  THE  OCULAR  NERVES.  105 

necessary  for  all  close  vision,  is  thus  much  better  provided  for  than  the 
opposite  action.     Voluntary  divergent  squint  is  impossible. 

The  motor  nerves  of  the  eye  may  be  diseased  (1)  at  their  nuclear 
origin,  (2)  in  their  intracerebral  course,  (3)  in  their  intracranial  course 
from  apparent  origin  to  their  cranial  outlets,  and  (4)  within  the  orbit. 
Four  groups  of  symptoms  are  produced  :  (1)  Pupillary  variations,  (2) 
disturbance  of  accommodation,  (3)  muscular  incompetence  and  squint, 
(4)  double  vision.  It  is  by  the  study  of  these  symptoms,  their  mutual 
combinations,  and  the  association  or  absence  of  other  cerebral  indica- 
tions that  a  distinctive  and  localizing  diagnosis  is  possible.  We  will 
first  consider  the  individual  nerves. 

Ocular  Palsies. — Complete  division  of  the  third  nerve  paralyzes  all 
the  extrinsic  muscles  but  the  external  rectus  and  the  superior  oblique. 
The  eye,  in  consequence,  can  be  turned  strongly  to  the  outer  canthus, 
and  eventually  becomes  fixed  in  that  position.  The  eyelid  droops  in 
complete  ptosis,  which  the  patient  tries  to  remedy  by  the  action  of  the 
frontalis.  The  pupil  is  widely  dilated  by  the  unopposed  action  of  the 
sympathetic,  and  does  not  react  for  light  or  accommodation.  The  eye, 
unless  strongly  myopic,  is  incapal^le  of  near  vision  through  the  loss  of 
accommodation  due  to  paralysis  of  the  ciliary  muscle.  There  is  double 
vision  excepting  when  the  sound  eye  is  made  to  correspond  with  the 
direction  of  the  one  paralyzed. 

Division  of  the  fourth  nerve  allows  the  eyeball  at  the  top  to  slightly 
rotate  outward  on  the  anteroposterior  axis,  which  corresponds  practi- 
cally to  the  line  of  direct  forward  vision.  AVhen  fixed  in  this  position 
by  the  action  of  the  inferior  oblique  and  the  inferior  rectus,  which  act 
together,  the  rotation  can  sometimes  be  observed  if  carefully  looked  for, 
but  the  index  to  this  paralysis  is  in  the  diplopia,  to  be  studied  later.      In 

1  2  3 

f%     f%     i/^ 


Fig.  37. — Paralysis  of  the  left  third  cranial  nerve.     1,    Ptosis;   2,    InefFectual  attempt  of  frontalis  to 
overcome  ptosis;  3  shows  partial  ptosis  and  outvcard  deviation  of  affected  eyeball. 


attempts  at  downward  convergent  vision  the  inward  rotation  of  the  eye- 
ball fails  to  take  place. 

When  the  sixth  nerve  is  divided,  the  eye  can  not  be  turned  outward 
from  a  line  marking  direct  forward  vision,  and  later  the  eye  becomes 
fixed  in  a  strong  inward  squint  that  may  carry  the  pupil  to  the  internal 
canthus.     The  diplopia  is  marked. 


106  DISEASES  OF  THE  CRANIAL  NERVES. 

Destructive  injury  to  the  sympathetic  produces  great  narrowing  of  tlie 
pupil,  as  the  pupillary  sphincter,  innervated  by  the  third  nerve,  escapes. 
At  the  same  time  the  eyeball  becomes  prominent  or  slightly  exophthal- 
mic by  reason  of  the  paralysis  of  Miiller's  muscles  and  the  retro-ocular 
turgescence.     The  pupil  does  not  react  for  light  or  for  pain. 

Diagnosis  of  Ocular  Palsies. — When  the  lesion  is  complete  and 
has  existed  some  time,  difficulty  in  deciding  which  extrinsic  muscle  is 
at  fault  is  not  very  great.  In  partial  lesions  and  when  the  condition 
is  vacillating  or  slight  in  degree,  a  careful  examination  is  required.  We 
have  two  important  indications — namely,  the  habitual  position  of  the  head 
and  the  dipAopna.  When  an  ocular  muscle  is  weakened,  the  patient  un- 
consciously and  constantly  so  carries  the  head  that  the  least  possible 
work  is  required  of  the  paretic  muscle.  For  instance,  if  the  right  ex- 
ternal rectus  is  involved,  the  patient  will  turn  the  head  to  the  right, 
thereby  relaxing  the  injured  muscle.  The  rule  as  laid  down  by  Land- 
holt  ^  is  that  the  direction  of  the  head  corresponds  in  every  icay  to  the  physi- 
ological action  of  the  paralyzed  muscle. 

If  the  visual  axes  for  both  eyes  do  not  attain  the  same  fixed  point, 
diplopia  results.  The  sound  eye  sees  the  fixed  object  clearly  and  the 
mind  refers  the  image  to  the  proper  position  in  space.  The  divergent 
or  convergent  eye  sees  the  fixed  object  indistinctly,  as  the  image  does 
not  fall  on  the  sensitive  spot  of  the  retina  and  the  mind  projects  it  to 
a  wrong  position  in  space, — namely,  to  the  position  by  experience  asso- 
ciated with  the  particular  part  of  the  retina  in  operation.  In  diplopia 
of  long  standing  the  mind  learns  to  neglect  the  weaker,  false  image,  and 
the  patient  may  be  unaware  of  his  double  vision.  The  eye  also  usually 
becomes  more  and  more  divergent,  presenting  the  comparatively  insensi- 
tive retinal  periphery  to  the  fixed  object,  and  this  assists  in  the  mental 
neglect  of  its  image.  When  the  muscle  weakness  is  very  slight,  diplo- 
pia only  occurs  on  quick  movements  of  the  eyes  or  in  extreme  range  of 
the  eye  in  the  direction  of  the  affected  muscle's  action,  and  then  it  may 
be  but  momentary,  the  muscle  under  the  stimulus  of  attention  gradually 
drawing  the  eye  into  line.  This  is  often  accomplished  in  a  jerky  man- 
ner. The  eyeball  presents  a  number  of  oscillations  which  may  termi- 
nate in  the  proper  position,  or  the  globe  may  swing  back  to  the  abnormal 
positioli,  the  muscle  being  quite  exhausted.  The  double  vision  and  the 
faulty  projection  at  first  invariably  give  rise  to  pronounced  ocular  vertigo. 

In  examining  a  case  of  diplopia  the  first  question  is  whether  it  is 
monocular.  Closing  one  eye  prevents  double  vision  unless  it  is  confined 
to  the  open  eye,  in  which  case,  if  not  due  to  defective  media  or  faulty 
curvatures,  it  is  almost  surely  hysterical.  Place  the  patient  in  a  good 
light,  have  him  hold  the  head  motionless,  and  let  him  follow  with  both 
eyes  the  point  of  your  finger  through  a  circular  range  about  a  foot  from 
his  face.*  At  some  angle  the  two  eyes  will  fail  to  maintain  parallelism, 
or  jerky  movements  of  one  eye  may  be  noticed.  The  point  is  to  determine 
which  is  the  affected  eye.  Cut  off  the  patient's  line  of  sight  from  one  eye^ 
with  a  card  held  at  such  a  distance  from  it  that  its  motion  can  still  be  ob- 
served, and  have  the  patient  fix  both  eyes  upon  your  finger  in  the  direc- 
1  "Brit.  Med.  Jour.,"  Sept.  15,  1894. 


DISEASES  OF  THE  OCULAR  NERVES. 


107 


tion  toward  which  conjugate  movements  failed.  If  the  sound  eye  be 
covered,  it  will  overact  and  be  turned  farther  to  the  side  than  is  re- 
quired. This  overaction,  or  secondary  deviation,  is  due  to  the  fact  that 
the  stimulation  necessary  to  draw  the  affected  eye  in  the  direction  of  the 
weak  muscle  is  more  than  sufficient  for  the  corresponding  sound  muscle. 
If  you  have  covered  the  weak  eye  in  the  same  way  it  will  not  move 
outward  far  enough  when  the  finger  is  fixed  by  the  sound  eye,  and  for 
a  similar  reason.  The  direction  of  failure  in  the  affected  eye,  therefore, 
points  to  the  weakened  muscle.  In  marked  squint  of  this  character 
the  affected  eye  often  presents  a  much  wider  range  of  motion  when  the 
sound  eye  is  covered  than  when  binocular  vision  is  attempted.  Appar- 
ently the  volitional  attempt  is  stronger  when  the  muscle  is  not  disturbed 


Fig.  38. 


Fig.  39. 


Fig.  38.  Convergent  squint.  The  ray  of  light,  a  c,  falls  to  the  riglit  of  the  sensitive  spot,  m,  of 
the  inturned  left  eye,  L.  Such  stimulus  has  always  been  recognized  by  the  mind  as  emanating  fiom 
objects  to  the  left,  and  not  realizing  the  disordered  position  of  the  ocular  globe  a  false  image,  e,  is  pro- 
jected an  additional  distance  to  the  left,  measuring  from  c  as  the  operating  sensitive  spot,  in  the 
line  d  e. 

F'ig.  39.— Divergent  squint.  The  ray  of  light,  a  c,  falls  to  the  left  of  the  macula,  m,  of  the  outwardly 
turned  left  eye,  L.  Such  stimulus  has  always  been  associated  with  objects  to  the  right,  and  the  false 
image,  e,  is  projected  to  the  right,  c,  acting  on  the  sensitive  spot  at  the  time. 


by  two  images.     Overaction  of  the  sound  eye,  however,  occurs,  as  in 
the  card-test. 

The  diplojna  test  is  made  as  follows  :  Place  the  patient  facing  a 
candle  or  bright  object,  such  as  a  narrow  strip  of  white  paper  the  size  of 
a  lead-pencil,  placed  on  a  dark  background  at  a  distance  of,  say,  twenty 
feet.  Cover  one  eye  with  a  red  glass.  If  there  is  double  vision,  the 
red  image  corresponds  to  the  covered  eye.  If  the  red  image  and  the 
covered  eye  are  on  the  same  side,  the  diplopia  is  simple ;  if  on  opposite 
sides,  the  diplopia  is  crossed.  When  the  eyes  converge,  the  diplopia  is 
simple  ;  when  the  eyes  diverge,  the  diplopia  is  crossed.  Gowers'  rule  is  : 
"  When  the  visual  lilies,  the  prolonged  visual  axes,  cross,  the  diplopia  is  not 


108  DISEASES  OF  THE  CRANIAL  NERVES. 

crossed.'^  If,  now,  the  fixing  object  remaining  stationary,  the  head  be 
turned  one  way  and  anotlier, — in  some  given  direction  the  images  will 
separate  and  in  the  opposite  direction  approach  and  perhaps  fuse. 
Landholt  ^  lays  down  this  rule  :  "  The  affected  eye  is  that  in  the  direction 
of  whose  image  the  diplopia  increases.^'  For  instance,  in  simple  diplopia, 
the  right  image  corresponds  to  the  right  eye.  If  the  diplopia  increases  on 
looking  to  the  right,  the  right  eye  is  affected.  In  crossed  diplopia  the 
left  image  corresponds  to  the  right  eye.  If  the  images  separate  on  look- 
ing to  the  left,  the  right  eye  is  at  fault  because  its  image  corresponds  to 
the  direction  of  the  increased  diplopia.  The  same  thing  is  true  in 
vertical  diplopia. 

He  also  lays  down  this  rule  :  "  The  paralyzed  muscle  is  the  one  which 
would  give  to  the  eye  the  direction  of  the  false  image."  The  false  image, 
of  course,  belongs  to  the  aifected  eye.  For  instance,  in  simple  diplopia 
with  the  right  eye  affected,  it  is  the  external  rectus  that  is  at  fault,  as  it 
is  this  muscle  which  would,  if  competent,  direct  the  eye  to  the  posi- 
tion of  the  false  image  at  the  right  of  the  true  image.  Involvement 
of  the  oblique  is  similarly  shown.  If  the  patient  indicates  that  the 
image  of  the  right  eye,  in  simple  diplopia,  is  to  the  right  and  its  upper 
end  leans  to  the  left,  we  know,  by  the  application  of  this  rule,  that  the 
right  superior  oblique  is  deficient.  An  opposite  condition  would  point 
to  the  inferior  oblique  and  inferior  rectus,  which  operate  together. 
,  The  location  of  the  lesion  determines  the  distribution  of  symptoms 
and  through  them  is  clinically  deciphered.  A  lesion  involving  the 
nuclei  under  the  aqueduct  of  Sylvius  is  almost  invariably  attended  by 
bilateral  symmetrical  eye  conditions.  This  is  due  to  the  anatomical 
proximity  of  the  centers  on  each  side  of  the  middle  line  and  to  their 
physiological  relations.  A  lesion  which  destroys  accommodation  and 
pupillary  contractions  affects  the  most  forward  group  of  nuclei.  If  the 
middle  group  is  involved,  all  the  extrinsic  muscles  of  the  eyes  are  dis- 
abled, even  the  external  recti,  as  this  group  has  a  controlling  influence 
over  the  nucleus  of  the  sixth  nerve.  If  the  lesion  fall  upon  the  sixth 
nucleus  alone,  double  convergent  squint  is  produced.  In  the  same  way, 
if  some  one  or  several  of  the  conjugate  movements  of  the  eyes  be  lost, 
or  a  double  ptosis  is  present,  the  lesion  is  nuclear  unless  movements  of 
the  head  and  trunk  are  lost  at  the  same  time.  In  such  case  the  lesion 
is  probably  above  the  nucleus  in  the  internal  capsule  or  in  the  cortex. 

The  three  ocular  nerves  leave  their  grouped  centers  by  widely 
diverging  routes,  and  may  be  cut  off  separately  and  unilaterally  by  en- 
cephalic conditions,  such  as  hemorrhage,  inflammation,  or  new  growths. 
Such  lesions  invariably  implicate  other  structures,  and  give  rise  to 
numerous  symptoms  other  than  those  referable  to  the  ocular  nerve. 
For  instance,  a  lesion  in  the  peduncle  in  the  region  of  the  red  nucleus 
would  disturb  the  motor  tracts  in  the  crus  and  produce  paralysis  on  the 
opposite  side  of  the  body,  with  paralysis  of  the  third  nerve,  ptosis,  etc., 
on  the  same  side  as  the  lesion.  This,  by  Charcot,  is  denominated  the 
symptom  group  of  Weber  (fig.  36). 

1  Loc.  cit. 


DISEASES  OF  THE  OCULAR  NERVES.  109 

In  basilar  inflatnmatious  and  injuries,  and  particularly  in  syphilitic 
meningitis,  the  ocular  neryes  are  likely  to  be  injured.  The  sixth,  from 
its  long  and  exposed  course,  is  especially  prone  to  injury  and  is  the  most 
frequently  diseased  nerye  of  this  group.  Lesions  in  this  position  are 
usually  unilateral,  and  if  bilateral  diifer,  as  a  rule,  in  degree  on  the  two 
sides.  Here  injury  to  the  third  nerye  necessarily  involyes  all  its 
branches  and  functions.  A  lesion  which  could  select  from  the  nerye- 
trunk  the  pupillary  fibers,  for  instance,  is  inconceivable.  Diifuse  cere- 
bral symptoms,  such  as  headache,  vertigo,  nausea,  stupor,  convulsions, 
and  optic  neuritis,  are  also  commonly  present.  At  the  apex  of  the  orbit 
all  the  ocular  nerves,  with  the  ophthalmic  division  of  the  fifth  and  the 
optic  nerve,  are  closely  approximated.  Injury  or  disease  at  this  point 
would,  therefore,  determine  complete  internal  and  external  ophthal- 
moplegia, impair  vision,  and  give  rise  to  sensory  disturbances  in  the 
distribution  of  the  supra-orbital  nerve.  Pressure  at  the  same  time  on 
the  return  orbital  circulation  congests  the  retinal  veins  and  produces 
some  exophthalmos.  After  the  nerves  have  separated  in  the  orbit,  any 
one  or  more  of  them  may  be  injured  by  traumatism  or  local  disease. 
Their  branches  may  be  singly  selected.  The  diagnosis  depends  upon 
the  muscles  involved,  and  the  anatomical  relations  of  the  nerves  and 
their  branches  within  the  orbit. 

Causes  of  Ocular  Palsies. — The  conditions  which  give  rise  to 
palsies  of  the  ocular  muscles  are  very  niunerous.  In  the  orbit  trauma- 
tism and  new  growths  are  frequently  causal  of  the  loss  of  ocular  move- 
ments. A  blow  over  the  eye  is  sometimes  followed  by  paralysis  of  the 
levator  palpebrse  superioris.  Exposures  to  cold  and  the  rheumatic  states 
are  sometimes  followed  by  an  ophthalmoplegia,  which  is  ])robal)ly  due  to 
a  peripheral  neuritis.  This  form  may  be  present  in  multiple  neuritis 
from  alcohol,  and  probably  from  other  poisons,  and  may  involve  few  or 
many  of  the  muscles.  Orbital  growths  usually  are  marked  by  exoph- 
thalmos. Cervical,  maxillary,  and  cranial  tumors  may  invade  the  orbit 
and  there  produce  these  local  symptoms. 

In  their  basilar  course  the  motor  nerves  of  the  eye  are  frequently 
injured  by  meningitis,  and  especially  by  syphilitic  disease.  Basilar 
fracture,  carotid  aneurysm,  or  the  pressure  of  neighboring  intracranial 
growths  may  also  implicate  them  in  this  localit}^ 

At  the  nuclei  multiple  sclerosis,  bulbar  palsy,  polioencephalitis  supe- 
rior, and  locomotor  ataxia  frequently  cause  ocular  palsies.  A  tempo- 
rary ptosis  or  diplopia  is  often  an  early  symptom  of  tabes,  and  should 
always  arouse  suspicion  of  it  or  of  syphilis.  The  exact  mechanism  and 
location  of  the  tabetic  disturbance  which  produces  the  ArgvU-Robertson 
phenomenon  is  not  understood,  but  presumably  the  anterior  cell-group, 
controlling  pupillary  and  ciliary  contractions,  is  involved. 

A  peculiar  periodically  recurring  or  relapsing  palsy  of  the  third  nerve 
is  sometimes  encountered.  It  is  more  frequent  in  females,  involves  only 
one  eye,  lasts  from  one  to  six  months,  and  returns  at  regular  intervals,  often 
during  the  entire  life  of  the  patient.  Its  pathology  is  not  known,  but 
the  nerve-trunk  has  several  times  been  found  to  be  diseased.  Traces  of 
this  palsy,  in  some  cases,  can  be  detected  during  the  intervals  of  practical 


110  DISEASES  OF  THE  CRANIAL  NERVES. 

freedom  from  the  trouble.  It  has  been  attributed  to  hysteria  in  certain 
instances,  and  is  frequently  associated  with  migraine,  the  so-called 
ophthalmoplegic  migraine. 

Lesions  of  the  cortex  or  of  the  internal  capsule  producing  hemiplegia 
are  often  attended  by  conjugate  deviation  of  the  head  and  eyes  toward 
the  sound  side  of  the  body,  but  if  the  paralyzed  side  present  convul- 
sions due  to  cerebral  irritation,  the  eyes  are  then  spasmodically  drawn  to 
that  side.  A  lesion  lower  down  in  the  pontine  region  would  be  marked 
by  a  crossed  deviation,  the  eyes  looking  to  the  paralyzed  side  of  the 
body,  and  in  convulsions  turning  to  the  sound  side  of  the  body. 

Ocular  Muscle  Spasms. — The  ocular  muscles  are  usually  associated 
with  the  other  muscles  in  generalized  convulsions,  the  eyes  turning  to  the 
side  most  vigorously  affected.  Individual  muscles  alone  are  affected  in 
very  rare  instances.  Tlie  levator  or  a  rectus  may  thus  be  spasmodically 
involved  for  years.  Sometimes  the  ocular  muscles  participate  in  facial 
tics  and  spasmodic  torticollis.  In  hysteria  the  eyes  are  frequently  rolled 
upward  and  outward,  or  strongly  converged  during  convulsive  manifes- 
tations of  the  disease,  and  these  ocular  positions  may  remain  for  long 
periods  of  time  after  the  convulsion  has  subsided.  A  more  common  eye 
condition  in  hysteria  is  one  of  spurious  double  ptosis.  It  is  really  a  spasm 
of  the  orbiculares.  The  patient  apparently  tries  to  overcome  it  by  raising 
the  brows  with  the  frontalis.  An  attempt  to  raise  the  lids  with  the  finger 
at  once  develops  resistance,  which  in  paralytic  ptosis  is  never  present. 

Nystagmus  consists  in  rapid  rhythmical  involuntary  oscillations  of 
both  eyeballs,  due  to  spasmodic  action  of  the  ocular  muscles.  When 
both  eyes  are  affected,  the  movements  are  similar  and  synchronous.  The 
spasmodic  movements  are  commonly  horizontal,  less  frequently  rotary, 
and  only  rarely  vertical.  When  the  eye  vibrates  in  one  plane,  it  ordinarily 
moves  outward  quickly  and  more  slowly  returns.  The  oscillations  vary 
in  number  from  fifty  to  two  hundred  or  more  a  minute,  and  in  extent 
from  one  to  ten  millimeters.  In  uremic  coma  the  eyes  will  sometimes 
be  noticed  in  a  rhythmical  movement  which  carries  them  through  their 
widest  lateral  range  about  ten  times  a  minute.  Nystagmus  may  be 
constant  or  only  provoked  by  calling  forth  a  particular  movement  of 
the  eyes,  as  by  directing  them  upward  or  outward.  This  latter  must 
not  be  confused  with  the  jerky,  unrhythmical,  and  momentary  move- 
ments of  weakened  muscles. 

The  causes  and  significance  of  nystagmus  are  often  obscure.  It  may 
be  acquired  as  the  sequel  of  any  condition  which  greatly  impairs  vision. 
Corneal  and  lenticular  opacities,  choroiditis,  and  retinitis  may  precede  it, 
especially  if  occurring  in  childhood.  Albinos  frequently  present  nys- 
tagmus. Miners  who  work  in  cramped  positions  with  poor  illumination 
acquire  it,  probably  as  a  fatigue  neurosis  through  the  overstrain  of  cer- 
tain eye-muscles  in  attempting  to  keep  the  work  in  view.  In  them  it 
is  often  only  present  when  the  particular  attitude  which  their  work 
requires  is  assumed. 

Nystagmus  is  present  incidentally  or  regularly  in  a  long  list  of  ner- 
vous diseases  which  have  neither  location  nor  pathological  anatomy  in 
common.     It  is  almost  a  cardinal  symptom  in  insular  sclerosis  and  in 


DISEASES  OF  THE  OCULAR  NERVES.  Ill 

hereditary  ataxia  of  the  Frieclreicli  type.  It  is  common  in  cerebellar 
tumor  and  tumors  involving  the  corpora  quadrigemina  and  optic  thalami. 
Occasionally  it  attends  sinus  tliroml)osis,  meningitis,  meningeal  hemor- 
rhage, and  variously  seated  cerel)ral  hemorrhages,  softenings,  and  tumors. 
Hysteria  has  also  furnished  rare  cases  of  persistent  nystagmic  ocular 
spasm. 

The  treatment  of  ocular  palsies  depends  upon  the  causal  con- 
dition and  is  often  most  unsatisfactory.  New  growths  and  traumata  are 
surgical  conditions  for  the  most  part.  Syphilitic  palsies  may  readily 
yield  to  treatment,  whether  due  to  basilar  or  central  involvement,  but 
only  too  often  recur,  yield  again,  and  finally  become  permanent.  The 
neuritic  form  is  treated  as  a  part  of  the  general  intoxication  usually  at 
the  bottom  of  the  disease.  A  persisting  ocular  deviation  is  often  bene- 
fited by  a  tenotomy.  Muscle  cutting  should  always  be  preceded  by 
exercise  of  the  muscles  with  prisms,  which  sometimes  is  helpful,  and  by 
general  treatment.  Nystagmus,  excepting  in  the  unusual  cases  where  it 
is  due  to  meningeal  and  sinus  diseases,  or  other  curable  lesion,  is  prac- 
tically unyielding  to  all  measures.  Miners'  nystagmus  usually  ceases 
when  the  occupation  is  changed. 


112  DISEASES  OF  THE  CRANIAL  NERVES. 


CHAPTER  VI. 
DISEASES  OF  THE  TRIFACIAL  NERVE* 

Anatomical  Considerations. — The  fifth  nerves  represent  the  sen- 
sory portions  of  all  the  motor  cranial  nerves.  Their  sensory  distribution 
embraces  most  of  the  skin  of  the  head  and  face,  all  their  mucous  membrane- 
lined  cavities,  and  the  cerebral  meninges  in  part.  In  addition,  through 
at  least  the  chorda  tympani,  the  fifth  subserves  the  special  sense  of  taste. 
Its  small  motor  root  innervates  the  mandibular  muscles  of  mastication. 
The  nuclear  origin  of  the  fifth  nerve  in  the  medulla  is  correspondingly 
extensive.  The  smaller  motor  nucleus  is  situated  under  the  floor  of  the 
fourth  ventricle  near  its  lateral  angle,  with  an  upward  extension  as  high 
as  the  corpora  quadrigemina.  Outside  of  this  is  the  larger  sensor}^ 
nucleus,  which  is  connected  continuously  with  nuclear  gray  matter  as 
low  as  the  fourth  cervical  spinal  segment.  These  centra  are  brought 
into  relation  with  the  cerebellum  and  with  the  cerebral  cortex  by 
upward  radiations.  For  the  motor  portion  the  cortical  centers  are  at  the 
foot  of  the  anterior  central  convolution.  The  sensory  cortical  repre- 
sentation is  not  clearly  known.  The  sensory  and  motor  trunks  leave 
the  surface  of  the  pons  separately,  though  side  by  side,  and  onlj^  after 
the  sensory  portion  has  passed  through  the  Gasserian  ganglion  does  the 
motor  trunk  join  the  third  trigeminal  division. 

According  to  Gowers  and  others,  the  strictly  gustatory  portion  fol- 
lows a  most  extraordinary  course  before,  as  the  chorda  tympani,  it 
reaches  the  liugual  nerve  and  is  distributed  to  the  anterior  portion  of 
the  tongue.  At  first  contained  in  the  sensory  trunk,  it  apparently 
passes  from  the  Gasserian  enlargemeut  with  the  middle  or  superior  max- 
illary branch.  Thence  it  drops  into  the  sphenopalatine  or  Meckel's 
ganglion,  and  turns  backward  in  the  form  of  the  A^idian  nerve,  to  pene- 
trate the  petrous  portion  of  the  temporal  boiie  and  join  the  facial  nerve 
in  the  Fallopian  aqueduct.  It  follows  the  facial  nearly  to  its  exit  at 
the  stylomastoid  foramen,  where  it  turns  sharply  upward,  reaching  the 
tympanic  cavity,  which  it  leaves  l^y  the  Gasserian  fissure.  It  then  de- 
scends between  the  pterygoid  muscles  and  joins  the  lingual  branch  of 
the  inferior  maxillary  or  third  trifacial  division,  to  be  distributed  to  the 
anterior  portion  of  the  tongue.  The  base  of  the  tongue  and  faucial 
pillars  also  recognize  taste  impressions.  It  is  supposed  that  these  sensa- 
tions reach  the  trunk  of  the  fifth  by  way  of  the  glossopharyngeal  nerve 
through  connections  with  Meckel's  ganglion.  AVe  know  certainly  that 
division  of  the  sensory  trunk  of  the  fifth  abolishes  all  taste  sensation  on 
the  corresponding  side  of  the  tongue  at  least  temporarily,  but  Gushing,  ^ 
after  an  elaborate  study  of  thirteen  cases  of  extirpation  of  Gasser's 
ganglion,  believes  that  the  sense  of  taste  ultimately  returns  to  that  area, 
and  that  the  gustatory  path  is  not  by  way  of  the  fifth  nerve. 
1  "Johns  Hopkins  Hosp.  Bull.,"  March-April,  1903. 


DISEASES  OF  THE  TRIFACIAL  NERVE. 


113 


Cortical  Diseases  of  the  Fifth  Nerve. — Lesions  of  the  portion 
of  the  motor  cortex  associated  with  the  fifth  nerve  produce  spasm  or 
paralysis  according  as  the  h^sion  is  irritative  or  destructive.  Tlie 
involved  muscles  are  the  pterygoids,  the  temporal,  and  the  masseter. 
In  generalized  convulsions  they  are  ordinarily  involved.  Very  rarely 
they  are  the  sole  seat  of  mott)r  disturbance  presenting  a  masticatory 
spasm  or  paralysis.  The  spasm  may  be  tonic,  as  in  trismus,  or  repeated 
at  varying  intervals.  The  teeth  are  tightly  clenched,  and  the  masse- 
ters  and  temporals  stand  out  firm  and  hard.  In  the  clonic  variety, 
as  in  the  chattering  of  a  chill,  the  lower  jaw  is  sharply  moved  laterally 
or  vertically.  Vigorous  grinding  of  the  teeth  may  be  present.  This 
is  sometimes  seen  in  the  late  stages  of  paretic  dementia  and  in  other 
wide-spread  organic  brain  disease.  Single  or  repeated  spasms  may  have 
their  origin  in  local  disease  of  the  jaws,  such  as  periosteitis  or  tooth- 
ache, and  are  then  reflexly  produced. 

Masticatory  paralysis  of  cortical  origin  is  extremely  rare.  The 
cortical  lesions  have  almost  invariably  been  found  to  be  bilateral,  but 


Fig.  40.— Distribution  of  tlie  sensory  cutaneous  nerves  on  tlie  head  :  Vi,  V^,  V3,  Tlie  three  branches 
-of  the  trigeminus  ;  oi,  auriculoteiuporai ;  io,  supraorljital ;  st,  supratrochlear;  i7,  iufratrochlear  ;  /,  lac- 
rynuil;  m,  mental;  6,  buccinator;  am,  auricularis  magnus:  «to,  subcutaneous  malse ;  onta,  occipitalis 
major  ;  oiiil,  occipitalis  minor  ;  cs,  superficial  cervical  (after  Hirt). 


Hirt  ^  has  reported  a  case  of  complete  mandibular  palsy  due  to  a  left- 
sided  lesion  at  the  foot  of  the  ascending  frontal  convolution. 

Nuclear  disease  of  the  fifth  nerve  is  usually  a  part  of  a  group  of 
bulbar  symptoms.  Masticatory  paralysis  arising  from  this  source  is  ex- 
tremely rare.  Progressive  bulbar  palsy  and  pontine  tumors  may  cause 
it,  but  other  cranial  nerves  are  almost  invariably  affected  at  the  same 
time.  Multiple  sclerosis  and  tabes  may  and  often  do  affect  the  fifth 
nucleus,  causing  bilateral  sensory  and  motor  symptoms  in  the  area  of 
its  distribution. 

8  1  "  Berlin,  klin.  Wochens.,"  1887. 


114 


DISEASES  OF  THE  CE AXIAL  NEBVES. 


Peripheral  intracranial  affections  of  the  trigeminus  may  involve 
the  stem,  the  Gasserian  oanglion,  or  the  three  branches  of  the  nerve  at 
their  exits  from  the  skull.  The  diiferential  diagnosis  as  to  location  may 
be  impossible  if  adjoining  nerves  or  structures  are  uninjured  or  present 
no  indications.  A  description  of  the  symptoms  arising  from  injurv  to 
the  trunk  will  therefore  apply  to  disease  of  the  Gasserian  ganglion  or  of 
the  three  branches  at  their  cranial  exits.  Growths  and  imflammatory 
processes  are  the  usual  causes  of  this  form  of  trifacial  disease. 

The  motor  symptoms  are  those 
of  paresis  or  paralysis  of  the  mandi- 
bular muscles.  The  jaws  can  not  be 
closed  or  can  not  be  firmly  held  to- 
gether when  closed.  The  combined 
strength  of  the  jaw-muscles  is  im- 
mense, and  considerable  impairment 
may  go  unnoticed.  In  complete 
bilateral  paralysis  the  jaw  droops, 
but  can  at  first  be  raised  by  the 
action  of  the  facial  muscles,  especi- 
ally the  buccinators  and  orbicularis 
oris.  If  the  palsy  is  one-sided,  the 
jaw  may  still  be  raised  by  the  uni- 
lateral action  of  the  uninjured  side, 
but  the  bite  is  feeble.  Attempts 
to  bring  the  paralyzed  pterygoids 
into  play  fail  to  produce  grinding 
movements,  so  that  the  jaw  can  not 
be  forcibly  advanced  from  the  im- 
paired side  or  thrust  in  the  opposite  direction.  In  long-standing  cases 
contracture  in  the  muscles  which  depress  the  jaw  may  permanently 
hold  the  mouth  open. 

Interference  with  sensation  may  be  partial  or  complete.  In  the  lat- 
ter case  all  parts  of  the  face,  head,  nasal  fossae,  conjunctivae,  mouth,  and 
tongue  supplied  by  the  fifth  nerve  are  insensitive,  and  taste  is  abolished 
on  that  side  of  the  tongue  and  oral  cavit^'.  Prodromal  pricking,  ting- 
ling, and  burning  usually  precede  the  anesthesia.  Frequently,  when  the 
loss  of  sensation  is  pronounced,  so  that  the  patient  no  longer  feels  a  pin- 
prick, complaints  are  made  of  pain  and  burning  in  the  anesthetic  area, — 
anaesthesia  dolorosa.  In  one  case  observed  by  the  writer,  while  general 
sensation  was  abolished  in  all  its  modes  and  tenses,  muscular  sense  re- 
mained. A  touch  or  prick  was  not  perceived,  but  the  slightest  motion 
communicated  to  any  facial  muscle  was  instantly  recognized,  apparently 
through  the  uninjured  seventh  nerve.  Trophic  disturbances  are  the  rule, 
but,  ordinarily,  they  are  slight  in  degree.  The  insensitive  conjunctiva 
and  cornea  are  easily  irritated  and  prone  to  ulceration  that  may  reach  a 
destructive  grade.  The  nasal  and  lacrimal  secretions  are  defective 
and  the  mucous  membrane  dry.  In  the  nose  this  dryness  impairs  the 
sense  of  smell.  The  paralyzed  side  of  the  tongue  is  thickly  furred, 
due  partly,  but  not  wholly,  to  the  fact  that  food  is  only  chewed  on  the 


Fig.  41.— Case  of  nuclear  disease  of  the  fifth 
cranial  nerve  iu  a  case  of  tabes,  sljowiiig  area 
of  ciitaueoiis  anesthesia;  some  facial  atrophy 
is  also  present. 


DISEASES  OF  THE  TRIFACIAL  NERVE.  115 

sound  side.  The  salivary  secretion  may  be  greatly  diminished.  Her])etic 
eruptions  in  the  cutaneous  distribution  are  frequent,  and  wlien  the  gan- 
glion or  branches  are  diseased  and  the  conjunctiva  is  involved,  constitute 
a  serious  feature,  as  ophthalmia  and  complete  loss  of  the  eye  may  ensue. 
Facial  hemiatrophy  may  follow  injury  and  disease  of  the  fifth  nerve. 
In  this  rare  deformity  tiie  wasting  is  always  limited  to  the  distribution  of 
the  trifacial,  and  is  usually  most  intense  in  the  field  of  the  middle  and  in- 
ferior divisions.  The  alleged  causes  in  numerous  instances,  such  as  blows 
on  the  head  and  face,  infectious  fevers,  exposure  to  cold,  facial  erysipelas, 
osteitis  of  the  jaws,  etc.,  are  capable  of  seriously  influencing  the  nerve.  In 
two  cases  histological  changes  in  the  trunk,  ganglion,  or  branches  have 
been  demonstrated,  and  atrophy  has  followed  division  of  the  root  of  the 
trigeminus  in  man  and  animals.  It  may  begin  in  a  widening  sclerodermic 
patch  on  the  side  of  the  face,  but  more  commonly  the  entire  half  of  the  face 
gradually  diminishes.     The  loss  affects  both  dermal  and  osseous  structures 


sW 


Fig.  42. — Two  early  cases  of  facial  heniiatioiihy. 

and  less  markedly  the  muscles,  which  may  escape  entirely.  The  o]-)p()site 
side  of  the  face  may  finally  become  involved,  though  this  is  rare.  The  dis- 
ease develops  usually  before  adult  life,  but  may  appear  at  any  age.  It 
produces  a  most  notable  difference  of  appearance  on  the  two  sides.  The 
atrophic  half  lacks  the  proportions  of  the  sound  side  in  every  particular. 
The  condition  is  usually  most  marked  in  the  lower  portion  of  the  face, 
gradually  lessening  upward  so  that  the  brow  may  show  almost  no  discrep- 
ancy on  the  two  sides.  The  skin  is  thinned  notably,  sometimes  to  a  half 
or  quarter  of  its  proper  thickness;  the  muscles  are  sometimes  reduced  in 
size  and  strength ;  the  lower  jaw  may  be  a  third  smaller  on  the  affected  side. 
The  teeth  are  often  lost.  As  the  skin  is  closely  applied  to  the  muscles  and 
the  bony  conformation,  a  cadaverous  appearance  is  presented  that  may  be 
strikingly  at  variance  with  the  plump,  healthy  side,  and  is  sometimes 
sharply  marked  by  a  furrow  at  the  middle  line  of  the  brow  and  chin.  The 
nose,  chin,  and  month  deviate  to  the  affected  side.  A¥hile  the  orbital  and 
palpebral  structures  are  frequently  wasted,  the  eyeball  is  affected  only  in 
rare  cases,  but  has  been  observed  wasted  and  even  destroyed.     The  dis- 


116 


DISEASES  OF  THE  CRANIAL  NERVES. 


ease  is  progressive  for  years,  but  may  come  to  a  standstill  at  any  time, 
and  again  advance.  It  seems  to  be  unmodified  by  treatment,  but  the  con- 
tinuous use  of  thyroids  may  be  tried  with  some  prospect  of  retarding  the 
progress  of  the  wasting,  especially  in  those  cases  showing  scleroderma. 

Disease  of  the  trifacial  branches  is  extremely  common.  Their 
course  through  bony  channels,  serving  to  protect  them  admirably  under 
ordinary  conditions,  exposes  them  to  pressure  from  inflammatory  states, 
to  injury  by  concussing  blows,  and  to  laceration  from  fractures  involving 
the  cranial  and  facial  bones.  Their  proximity  to  the  nasal,  buccal,  and 
j^haryngeal  cavities,  always  containing  the  potential  factors  of  infection, 
is  a  local  disadvantage.  Finally,  they  are  distributed  to  the  most  ex- 
posed portion  of  the  cutaneous  expanse,  where,  thinly  covered,  they  rest 
upon  unyielding  structures. 

They  are  very  often  the  seat  of  neuralgie  pain,  which  will  be  more  par- 
ticularly considered  in  the  section  on  Symp- 
tomatic Disorders  of  the  Nervous  System, 
Part  A'^III.  It  is  probable,  however,  that  a 
nerve,  the  seat  of  long-continued  neuralgic 
pain,  symptomatic,  perhaps,  of  a  general  blood 
state, — as  malaria,  for  instance, — may  even- 
tually become  histologically  changed  and  or- 
ganically diseased.  A  neuritis  may  be  thus 
established  which  is  usually  marked  by 
sharply-defined  anatomical  areas  of  hyjjer- 
sensitiveness  or  anesthesia.  Dystrophic 
changes  in  the  dermal  structures,  such  as  scal- 
iness,  herpes,  and  falling  or  discoloration  of 
the  hair  of  the  eyebrow  and  beard,  are  fre- 
quently encountered.  The  glands  supplied  by 
the  given  nerve  over-  or  underact  as  the  con- 
dition in  the  nerve  is  irritative  or  destructive. 
Neuritis  may  also  be  set  up  by  extension  from 
a  neighboring  inflammation  in  the  orbit,  an- 
trum, or  jaws.  The  dental  branches  are  par- 
ticularly liable  to  infection,  injury,  and  irrita- 
tion, which  in  the  case  of  molar  teeth  is  not  infrequently  the  cause  of 
pain  referred  to  other  branches  of  the  trifacial  than  the  one  immediately 
concerned. 

Injury  to  the  lingual  branch  of  the  third  division  of  the  fifth  nerve, 
if  it  occurs  below  the  junction  of  the  chorda  tympani,  produces  loss  of 
taste  on  the  anterior  portion  of  the  tongue  on  the  same  side,  in  addition 
to  the  loss  of  general  sensation  and  trophic  disturbance  in  its  anatomical 
area  of  distribution. 

The  motor  fibers  of  the  trifacial,  being  entirely  confined  to  the  third 
division,  suffer  with  it.  Paresis  or  paralysis  of  the  muscles  of  mastication 
on  the  same  side  follows.  The  prominence  and  hardness  of  the  masseter 
and  temporal  do  not  take  place  when  the  patient  attempts  to  clench  the 
teeth,  and  deviation  of  tlie  chin  to  the  opposite  side  can  be  but  feebly  pro- 
duced or  is  lacking.      Destruction  of  the  motor  root,  either  above  or  below 


Fig.   43. — Case  of  facial   hemiatrophy 

(after  Yonge). 


DISEASES  OF  THE  FACIAL  NERVE. 


117 


the  ganglion  or  at  the  bulbar  nucleus,  gives  rise  to  muscular  atrophy  in 
the  muscles  of  nuistication,  and  to  the  reaction  of  degeneration  upon  their 
electrical  stimulation.      A  cortical  lesion  causes  no  such  degeneration. 


CHAPTER  VII. 
DISEASES  OF  THE  FACIAL  NERVE. 

Anatomical  Considerations. — The  seventh  cranial  nerve  has  its 
cortical  origin  or  representation  in  the  lower  Rolandic  region.  The 
nuclear  center  is  situated  under  the  floor  of  the  fourth  ventricle,  to 
the  inner  side  of  the  ascending  root  of  the  fifth  nerve.  The  path- 
ways between  nuclei  and  cortex  decussate  in  the  median  raphe  (Ed- 
inger).  From  the  nuclear  cells  the  nerve  passes  close  to  the  nucleus 
of  the  sixth  nerve,  and,  descending  thence  through  the  pons,  emerges 
in  the  furrow  between  the  pons  and 
medulla  outside  the  sixth  nerve,  closely  , 

accompanied  by  the  eighth  or  audi- 
tory nerve,  with  which  it  proceeds  di- 
rectly to  the  internal  auditory  meatus. 
Its  relation  to  the  sixth  nucleus  and 
its  proximity  to  the  sixth  nerve  on 
emergence  explain  the  frequent  asso- 
ciation of  these  nerves  in  disease.  The 
parallel  course  of  the  auditory  and 
facial  from  medulla  to  meatus  explains 
why  meningeal  and  basilar  conditions 
of  necessity  affect  them  both  at  the 
same  time. 

The  nucleus  of  the  seventh  re- 
ceives fibers  from  the  oculomotor  nu- 
clei above,  which  are  destined  to  the 
orbicular  muscle  of  the  eyelids.  By 
this  mechanism  the  functions  of  wink- 
ing, accommodation,  and  ocular  move- 
ments   are    associated.       Fibers    from 

the  hypoglossal  nucleus  below  also  pass  to  the  nuclear  centers  of  the 
seventh,  and  are  eventually  distributed  to  the  orbicular  muscle  of  the 
mouth,  correlating  the  labial  and  lingual  movements  necessary  in 
phonation,  mastication,  and  other  buccal  processes. 

The  decussation  of  the  seventh  explains  the  phenomena  of  crossed  or 
alternate  paralysis  of  the  face  and  limbs.  A  lesion  in  the  pons  above 
the  decussation  involves  at  once  the  seventh  nerve  and  the  pyramidal 
tract  for  the  opposite  side  of  the  body,  but  below  the  facial  crossing  and 
above  the  pyramidal  decussation  a  lesion  involves  the  face  on  the  same 
side  and  the  limbs  on  the  opposite  side.  Such  a  lesion  must  involve 
the  lower  third  of  the  pons,  approximately  the  portion  below  the  super- 
ficial origin  of  the  fifth  pair. 


Fig.  44. — Diagram  showing  the  course 
of  facial  and  pyramidal  fibers  and  the  re- 
lations of  cranial  nerve-trunks.  A,  Le- 
sion causing  one-sided  symptoms  ;  B,  lesion 
causing  crossed  paralysis  of  the  face  on  one 
side  and  the  limbs  on  the  other. 


118 


DISEASES  OF  THE  CRANIAL  NERVES. 


After  entering  the  internal  auditory  meatus  the  seventh  nerve  bends 
somewhat  sharply,  and  presents  a  gangliform  swelling,  which  receives  the 
large  superficial  petrosal  from  the  Vidian  nerve  containing  the  taste-fibers 
from  the  second  branch  of  the  fifth  nerve  by  way  of  the  sphenopalatine 
ganglion.  The  taste-fibers  leave  the  facial  nerve  in  the  form  of  the  chorda 
tympani  after  it  has  almost  completely  traversed  the  Fallopian  canal,  and, 
passing  up  through  the  tympanum,  finally  reach  the  anterior  portion  of  the 
tongue  with  the  lingual  branch  of  the  fifth.  Within  the  Fallopian  canal 
the  facial  gives  oif  from  within  outward,  first,  near  the  ganglion  of  the 
knee,  above  mentioned,  a  motor  branch  to  the  tympanic  plexus  ;  second, 
a  motor  branch  to  the  stapedius  muscle ;  and,  third,  the  chorda  accom- 
panied by  a  secretory  branch 
to  the  salivary  glands.  The 
facial  nerve,  therefore,  within 
the  aqueduct  contains  (I)  motor 
filaments  for  the  facial  muscles, 
(2)  filaments  of  the  special 
sense  of  taste  for  the  anterior 
two-thirds  of  the  tongue,  (3) 
motor  filaments  for  the  internal 
ear,  and  (4)  secretory  fibers  for 
the  salivary  glands.  In  addi- 
tion there  are  a  few  filaments 
subserving  common  sensation 
for  the  external  ear,  derived 
from  the  fifth  nerve,  which 
pass  with  the  facial  to  its 
exit. 

After  leaving  the  stylomas- 
toid foramen  the  fiicial  gives 
otf  (1)  the  sensory  branches 
above  referred  to,  (2)  branches 
to  the  external  auricular  mus- 
cles, and  (3)  branches  to  the 
posterior  portion  of  the  occi- 
pitofrontalis.  The  trunk  in 
the  substance  of  the  parotid 
then  divides  into 
spread  branches 
motion  to  all  the 


throue 


St.  F,   stylo- 


Fig.  45. — Diagram  of  facial  nerve  passing 
the    petron.     F,    Facial;    A,   auditory;    St. 
mastoid   foramen;   Cli,  chorda;  S,  S,   salivary  fibers; 
O,  G,  gustatory  fibers ;  St,  brancli  to  stapedius  mus- 
cle ;  T,  tympanic  branch. 


(4)   widely 

supplying 

muscles    of 

the  face,  to  the  platysma,  the  stylohyoid,  and  the  posterior  belly  of  the 
digastric. 

Practically,  the  seventh  nerve  may  be  considered  one  of  pure  motion. 
It  furnishes  the  trophic  supply  to  the  muscles  of  the  face.  The  sensory 
and  secretory  filaments  merely  join  it  during  its  course  and  leave  it 
before  it  reaches  its  periphery.  When  it  is  diseased  the  major  symp- 
toms are  motor  and  consist  of  increased  or  decreased  activity,  giving  rise 
to  facial  spasm  or  facial  palsy  as  the  condition  is  one  of  irritation  or 
deficit.  The  muscles  also  waste.  The  addition  of  sensory  and  secretory 
disturbances  enables  us  to  locate  the  lesion  with  more  or  less  exactness. 


DISEASES  OF  THE  FACIAL  NERVE.  119 

Spasmodic  Affections  of  the  Facial  Nerve. — Facial  Spasm, — 
Irritative  lesions  in  tlie  Rolandic  faee-centers  may  set  up  grimacing 
spasms  on  the  opposite  side,  usually  of  an  unrhythmical,  clonic  sort, 
which  are  not  suggestive  of  any  intention.  Such  a  spasm  may  be 
the  initial  feature  of  a  Jacksonian  fit.  Grimacing  is  the  feature  of 
all  severe  epileptic  attacks  that  most  impresses  onlookers.  In  limited 
cortical  lesions  in  the  face-centers  the  spasm  may  be  confined  to  a  por- 
tion of  the  face,  as  to  the  angle  of  the  mouth  or  to  the  eyelids  and  brow. 
These  cortical  spasms  are  usually  attended  by  mental  symptoms,  such  as 
an  aura,  confusion,  or  unconsciousness,  and  are  practically  independent  of 
circumstances  and  surroundings.  Feelings  of  apprehension  and  a  dis- 
tressed appearance  commonly  attend  them.  Their  frequency  is  variable. 
Often  they  occur  singly,  at  long  and  irregular  intervals.  An  explosion, 
a  sort  of  status,  may  take  place  so  that  the  face  is  convulsed  for  many 
minutes  or  even  hours,  and  then  returns  to  a  normal  quietude,  perhaps 
marked  by  a  slight  paresis  or  even  by  a  distinct  weakness,  which  is  im- 
portant and  should  always  be  sought. 

The  irritative  lesion  may  be  subcortical  and  produce  the  same  con- 
ditions. At  the  nuclear  level  it  would  almost  certainly  involve  other 
cranial  nerves.  Pontine  and  basilar  growths  have  in  rare  instances 
been  the  cause  of  such  facial  spasms,  and  inflammatory  invasion  of  the 
nerve-trunk  is  usually  marked  by  twitchings  in  the  muscles  which  sub- 
sequently present  palsy.  These  twitchings  often  reappear  with  regenera- 
tion.    All  the  above  conditions  produce  a  pure  spasm. 

The  muscles  supplied  by  the  fiicial  nerve,  either  alone  or  more 
commonly  in  conjunction  with  other  groups,  may  be  affected  by  spas- 
modic tics,  including  blepharospasm,  mimic  spasm,  grimacing,  etc.  These 
are  ordinarily  the  external  manifestation  of  a  fixed  idea,  and  will  be 
described  under  the  psychoneuroscs  in  Part  VII. 

Paralysis  of  the  Seventh  Nerve. — Facial  palsy  follows  lesion  of 
the  seventh  nerve  at  any  point  from  the  cortex  to  the  stylomastoid  fora- 
men. In  the  face  individual  branches  may  be  injured,  with  corre- 
sponding local  motor  loss.  The  most  complete  facial  paralysis  depends 
upon  injury  to  the  nerve-trunk.  When  it  follows  exposure  to  cold  or 
occurs  in  rheumatic  conditions  it  is  often  called  BeWs  palsy.  The  per- 
ipheral form,  due  to  a  lesion  of  the  nerve-trunk  after  its  entrance  into 
the  petron  through  the  internal  meatus,  will  first  be  considered,  and  then 
the  nuclear  and  central  varieties. 

Peripheral  Facial  Palsy. — Etlolog-y, — The  facial  nerve  in  the 
petrous  canal  is  occasionally  invaded  by  inflammation  extending  from 
the  tympanic  cavity.  The  separating  plate  of  bone  is  often  of  extreme 
thinness,  and  may  even  be  lacking,  especially  in  children.  Mastoid 
disease  and  pharyngeal  inflammations  have  led  to  the  same  result. 
Fractures  of  the  cranial  base  very  frequently  involve  the  petron,  and 
may  cause  a  facial  palsy  at  once  ;  or  this  may  come  on  from  inflam- 
matory reaction  after  a  few  days,  or  later  from  the  deposition  of 
callus.  In  extremely  rare  instances  hemorrhage  within  the  canal  pro- 
duces paralysis  almost  instantly.  In  some  infantile  cases  a  cerebellar 
hemorrhage  invades  the  canal  with   the   same  result.      Injuries  to  the 


120  DISEASES  OF  THE  CRANIAL  NERVES. 

nerve  at  its  foramen  of  exit,  as  by  blows  with  sharp  or  blunt  instru- 
ments and  by  the  obstetrical  forceps,  may  cause  the  palsy.  In  addition 
to  the  local  disadvantage  presented  by  the  facial  nerve  being  surrounded 
by  a  long  bony  passage,  Neumann  attributes  much  to  the  large  number 
of  lymphatics  and  lymphatic  glands  encircling  it  at  its  exit  from  the 
stylomastoid  foramen.  Stagnation  of  lymph  here  favors  changes  in  the 
neighboring  nerve-trunk.  Upv/ard  extension  of  inflammation  in  the 
parotid  or  side  of  the  neck  into  the  canal  is  an  occasional  cause.  By  all 
odds  the  most  common  and  usual  cause  is  a  neuritis  due  to  cold,  as  by 
a  draft  of  air  on  the  side  of  the  face  during  the  night,  or  from  an 
open  window,  or  after  prolonged  outdoor  exposure.  The  nerve-swelling 
to  which  this  gives  rise  nips  the  nerve  in  its  unyielding  channel  and 
paralysis  supervenes. 

Huebschmann,  1  from  a  series  of  135  cases,  found  seventy-five  per 
cent,  to  be  of  the  so-called  rheumatic  form,  nine  per  cent,  due  to  ear  disease, 
and  six  per  cent,  to  injury.  Most  of  the  rheumatic  cases  occurred  be- 
tween the  ages  of  ten  and  forty  years,  and  males  predominated  about  five 
to  four.  Reik  ^  believes  that  the  so-called  rheumatic  variety  of  facial 
palsv  is  very  commonly  dependent  upon  catarrhal  or  other  inflammation 
of  the  middle  ear,  and  urges  an  examination  for  otitis  media  in  every  case. 

Any  general  depression  of  the  physical  state  may  act  as  a  predis- 
posing element.  In  this  relation  rheumatism  occupies  a  chief  place. 
Anemia,  syphilis,  tuberculosis,  and  alcoholism  are  also  very  favoring 
conditions,  as  is  the  puerperium.  Syphilis  may  of  itself  cause  a  local 
lesion,  but  must  at  this  location  act  very  exceptionally.  Gouty  and 
leukocythemic  neuritis  may  also  involve  the  facial  trunk  directly. 

Symptoms. — Motor. — In  a  well-marked  case,  unless  due  to  direct 
violence,  within  about  twenty-four  hours  after  the  action  of  the  inciting 
cause  a  little  twitching  in  the  aifected  side  of  the  face  is  frequently  noticed. 
Perhaps  friends  then  first  call  attention  to  the  distortion  of  the  face,  which 
in  all  expressional  movements  is  drawn  to  the  opposite  side.  The  patient 
may  first  find  that  he  is  unable  to  expectorate  with  certainty,  to  whistle, 
or  to  puif  out  his  cheeks  and  lips,  owing  to  the  loss  of  control  over  the 
labial  positions.  In  two  or  three  days  the  deformity  is  noticeable  to 
all.  The  entire  side  of  the  face  is  aifected,  Avith  the  occipitofrontalis. 
Even  the  small  muscles  of  the  external  ear  on  the  same  side  are  para- 
lyzed. The  unopposed  muscles  of  the  sound  side  dra^v  the  mouth  in 
their  direction,  and  the  zygomatici  elevate  its  angle.  When  the  mouth 
is  opened  widely  it  presents  an  unsymmetrical  outline.  It  is  higher  on 
the  sound  side  and  displaced  to  this  side  of  the  middle  line.  This  may 
mechanically  cause  the  projected  tongue  to  deviate  to  the  sound  side, 
but  if  the  mouth  be  passively  held  in  a  median  position,  the  lingual 
curve  disappears  and  full  mobility  of  the  tongue  can  be  easily  shown. 
The  dorsum  of  the  tongue  is  slightly  depressed  on  the  aifected  side, 
according  to  Schultze,^  from  weakness  of  the  stylohyoid  and  digaster. 
Saliva  and  food  accumulate  in  the  flabby  cheek  and  have  to  be  dis- 

1  "Neurol.  Centralblatt, "  Nov.  15  and  Dec.  1,  1894. 

2  "Johns  Hopkins  Hosp.  Bull.,"  April,  1902. 
'  "Miineh.  med.  Wochens.,"  June,  1897. 


DISEASES  OF  THE  FACIAL  NERVE. 


121 


placed  with  the  finger.  Mastication,  therefore,  is  mainly  done  on  the  sound 
side  and,  due  largely  to  this  fact,  lateral  furring  of  the  tongue  on  the  par- 
alytic side  may  appear,  (^ftcn  there  is  some  diminution  of  salivary  flow 
on  the  paralyzed  side,  owing  to  the  involvement  of  the  secretory  fibers 
which  traverse  the  facial  trunk.     The  nasolabial  fold  disappears  on  the 


Fig.  46.— Facial  palsy  of  left  side.     1,  Bilateral  attempt  to  raise  eyebrows;  2,  bilateral  attempt  to  close 

eyes;  3,  smiling. 

injured  side  and  is  accentuated  on  the  sound  side.  The  chin  and  nose  may 
deviate  to  the  sound  side.  The  eye  on  the  paralyzed  side  can  not  be  closed 
nor  the  eyebrow  lifted.  In  attempts  to  close  the  eyes  the  one  on  the 
affected  side  turns  upward  and  can  not  be  controlled.  Winking  is  absent, 
and  in  the  aged  the  lower  lid  often  droops  away  from  the  ball.  The 
cross-wrinkles  on  the  forehead  stop  abruptly  at  the  middle  line. 


Fig.  47. — Facial  palsy  of  left  side.    4,  forced  effort  to  uncover  teeth  on  both  sides ;  5,  protruded 
tongue  in  middle  line ;  6,  mouth  open  more  widely  on  sound  side  in  bilateral  effort. 


During  moments  of  quiet  little  asymmetry  may  be  apparent,  but  the 
slightest  emotional  or  voluntary  movement  produces  and  accentuates  all 
the  motor  symptoms.  In  young  patients,  where  the  expressional  lines  and 
wrinkles  are  al3sent  or  only  slightly  developed,  the  difference  between  the 
two  sides  is  much  less  marked  than  in  those  of  more  mature  years.     The 


122 


DISEASES  OF  THE  CRANIAL  NERVES. 


greater  resilience  of  the  skin  and  the  larger  adipose  layer  contribute  to  the 
same  thing.  The  reaction  of  degeneration  is  present  in  the  muscles  either 
in  complete  or  modified  degree.  The  muscle  reflexes  are  abolished  and 
after  a  few  weeks  the  muscles  waste.  The  atrophic  loss  is  not  readily  seen 
except  in  thin  people.  As  the  eye  can  not  be  closed,  the  exposed  conjunc- 
tiva is  often  irritated  and  painful.  At  night  it  may  become  quite  dry,  and 
conjunctivitis  of  a  severe  grade  may  develop.  From  the  relaxation  of  the 
lids  the  natural  How  of  tears  to  the  lacrimal  duct  is  interrupted  and  they 
overflow  on  to  the  cheek.  In  rare  severe  cases  there  is  a  herpetic  eruption, 
but  this  is  probably  due  to  a  simultaneous  affection  of  the  fifth  nerve. 

Disturbance  of  common  sensation  is  slight  or  wanting.  If  in  the  first 
week  the  muscles  of  the  cheek  be  grasped,  some  tenderness  can  be  elicited, 
which  is  probably  due  to  the  irritation  of  the  sensory  twigs  distributed  to 
the  degenerating  facial  branches.  The  sense  of  taste  on  the  same  side  of 
the  tongue  in  its  anterior  two-thirds,  the  part  supplied  by  the  chorda  tym- 

pani,  is  often  disturbed  or 
abolished.  Many  patients 
during  the  first  few  days  ac- 
knowledge subjective  taste 
sensations  of  a  peculiar  sort; 
but  ordinarily  a  careful 
search  must  be  made  in  order 
to  elicit  the  actual  difficulty. 
Hearing  is  sometimes  modi- 
fied in  such  a  way  that  low 
notes  are  more  readily  heard 
than  on  the  sound  side,  while 
those  of  high  pitch,  as  the 
ticking  of  a  watch,  are  not 
distinguished  with  even  or- 
dinary acuteness.  Middle- 
ear  inflammation,  if  present,  would  be  attended  by  some  general  loss  of 
hearing  and  sometimes  by  tinnitus. 

In  rare  instances  a  double  facial  palsy  is  encountered.  This  usually  is 
significant  of  intracranial  disease,  as  pontine  lesions,  inflammation  (espe- 
cially of  a  syphilitic  sort)  at  the  base,  or  nuclear  degeneration,  which  ordi- 
narily involves  other  cranial  nerves  at  the  same  time.  A  double  otitis 
may  produce  it,  or  it  may  be  part  of  a  multiple  neuritis,  such  as  follows 
diphtheria  and  other  general  intoxications.  In  bilateral  palsy  the  face 
hangs  flabby,  motionless,  and  without  expression.  The  unwinking  eyes  and 
the  drooping  mouth  give  a  vacuous  look  that  is  suggestive  of  dementia. 
All  of  the  paralytic  symptoms  are  present  on  both  sides,  but  the  distor- 
tions and  asymmetry  so  prominent  in  the  ordinary  form  are  wanting. 

Course. — The  tendency  of  the  palsy  to  improve  in  peripheral  facial 
paralysis  is  marked,  excepting  in  destructive  lesions  of  the  nerve-trunk. 
Cases  that  improve  get  practically  well  in  from  three  w'eeks  to  eighteen 
months,  depending  upon  the  amount  of  injury  done  the  nerve  and  the 
duration  of  pressure  within  the  facial  canal.  This  is  true  regardless  of 
treatment  in  those  cases  that  depend  upon  so-called  rheumatic  condi- 
tions, though  improvement  may  without  doubt  be  accelerated  by  proper 


Fig.  48. — Facial  palsy  of  left  side.  7,  Effect  of  faradism  on  sound 
side  ;  8,  non-effect  of  same  current  on  naralvtic  side. 


DISEASES  OF  THE  FACIAL  NERVE. 


123 


management.  The  early  loss  of  faradic  stimulability  of  the  muscles 
gradually  passes  away,  but  voluntary  motion  returns  before  the  faradic 
current  regains  its  control.  Very  frequently  the  paralyzed  muscles  will 
twitch  or  even  act  in  vigorous  spasm  as  regeneration  in  the  nerve  re- 
stores its  irritability.  Those  cases  which  last  a  month  or  two,  or  more, 
usually  leave  traces  for  the  rest  of  life.  They  may  be  so  slight  as  to 
require  careful  scrutiny,  or  marked  weakness  may  remain.  A^ery  excep- 
tionally the  palsy  is  permanent. 


Fig.  49. — Same  ease  six  months  later.  9  shows  late  contracture  on  the  jiaretio  side  while  the  face 
is  at  rest ;  10,  contracture  in  the  lower  half  of  the  face  increased  by  gently  closing  the  eyes,  and  at  the 
same  time  shows  weakness  about  left  eye;  11,  contracture  increased  by  raising  brows,  showing  over- 
action  of  zygomatic!  and  weakness  of  frontalis  on  left  side. 


As  the  face  recovers,  in  every  instance  the  paretic  side  is  likely  to 
overact  for  all  moderate  voluntary  bilateral  movements.  It  would  seem 
that  the  neuritis  had  left  a  certain  nuclear  irritability,  so  that  a  central 
influence,  acting  equally  on  both  sides,  produces  a  greater  effect  on  the  for- 
merly paralytic  muscles.  This  secondary  overaction  is  most  pronounced 
in  the  lower  half  of  the  face,  and  often  leads  the  patient  to  suppose  that 
the  sound  side  is  becoming  paretic.  When  once  strongly  developed  it 
practically  remains  for  the  rest  of  life,  though  slight  degrees  of  it  may 
pass  away.  While,  therefore,  the  paralysis  usually  gets  well,  the  sequel 
often  remains  and  is  irremediable,  but  is  not  of  great  amount  or  serious 
import.  Indeed,  many  people  who  have  never  been  aifected  show  almost 
as  much  asymmetry  of  facial  muscular  action.  Some  cases  present  sev- 
eral attacks  of  facial  palsy.  Bernhardt  ^  asserts  that  recurrence  takes 
place  in  70^  of  all  cases  and  in  men  more  commonly  than  in  women. 
Second  attacks  are  frequently  associated  with  middle  ear  inflammation, 
syphilis,  or  diabetes.  In  the  authors'  experience  second  attacks  are 
decidedly  uncommon.  Rossolimo  ^  reports  a  recurring  case  associated 
with  migrainous  attacks. 

Diagnosis. — The  diagnosis  of  a  facial  palsy,  if  at  all  marked,  is 
made  at  a  glance  in  the  early  stage.  Later  on  the  secondary  overaction 
may  momentarily  mislead,  but  its  nature  should  be  easily  deciphered. 
In  slight  volitional  movements  the  overacting  and  consequently  for- 
merly paralyzed  side  of  the  face  responds  in  an  exaggerated  manner; 

1  "Neurol.  Ceiitralblatt.,"  1899. 

2  "Neurol.  Centralbl.,"  Aug.,  1901. 


124  DISEASES  OF  THE  CRANIAL  NERVES. 

but  if  the  muscular  effort  be  forced,  as  in  vigorously  screwing  up  the 
eyes  and  in  laughing,  the  paresis  will  be  manifest  in  the  lessened  action 
of  the  orbicularis  palpebrae,  though  at  the  same  time  the  zygomatic!  on 
the  same  side  may  be  strongly  overacting  and  exaggerating  the  naso- 
labial furrow.  In  the  same  way  a  strong  attempt  to  uncover  the  teeth 
will  show  a  weakness  on  the  affected  side.  The  distinction  between  a 
cerebral  and  a  peripheral  palsy  will  be  made  clear  in  the  consideration 
of  lesions  within  the  skull.  It  suffices  here  to  say  that  disease  of 
the  cortex  and  in  the  brain  above  the  nuclei,  as  in  ordinary  hemiplegia, 
produces  no  muscular  atrophy,  no  reaction  of  degeneration  in  the  muscle, 
and,  with  practical  uniformity,  never  involves  the  brow  and  is  most 
marked  in  the  lower  portion  of  the  face.  The  tongue  also  is  affected,  as 
a  rule.  Lesions  at  the  nucleus  and  in  the  pons  almost  invariably  im])li- 
cate  other  cranial  nerves.  Lesions  at  the  base,  as  in  meningitis,  affect 
other  cranial  nerves  usually,  and  always,  when  the  face  is  paralyzed,  pro- 
duce deafness  from  injury  of  the  more  vulnerable  auditory  nerve,  the 
parallel  course  of  which  with  the  facial  has  been  pointed  out. 

The  question  as  to  the  location  and  extent  of  the  lesion  in  the  usual 
peripheral  palsy  is  an  interesting  one,  and  can  be  answered  with  some 
degree  of  precision.  Referring  to  the  diagram,  page  118,  it  is  evident 
that  the  neuritis,  unless  confined  to  a  very  short  distance  above  the  stylo- 
mastoid foramen,  will  (1)  involve  the  chorda  and  (2)  produce  loss  of 
taste  on  the  same  side  of  the  tongue,  with  diminished  salivation.  A  little 
higher  (3)  the  tympanic  tensor  nerve  is  cut  off'  and  the  auditory  symp- 
toms of  hyperacousis  for  low  tones,  with  blunting  of  hearing  for  notes 
of  high  pitch,  will  be  added.  At  the  internal  (4)  meatus  the  auditory 
nerve  will  also  suffer  and  the  chorda  may  escape. 

Prognosis. — The  prognosis,  while  very  good  for  practical  recovery 
in  all  cases  of  facial  neuritis,  should  always  be  guarded  and  guided  by 
an  electrical  examination,  which,  after  the  second  week,  often  furnishes 
information  of  a  precise  nature.  Simple  slight  cases  present  no  diminu- 
tion in  faradic  response  or  change  in  galvanic  excitability.  They  may 
be  expected  to  recover  within  a  month.  If  galvanism  and  faradism  of 
the  nerve  give  diminished  responses  and  galvanism  of  the  nmscles  shows 
increased  influence,  with  A.  C.  C.  equal  to  or  greater  than  C.  C.  C,  the 
case  will  probably  last  two  or  three  months.  Finally,  if  the  reaction  of 
degeneration  be  complete,  no  responses  in  the  nerve  to  either  current, 
the  muscles  refusing  to  act  to  faradism  and  showing  overexcitability  to 
galvanism  with  the  anode  overpassing  the  cathode,  a  year  to  eighteen 
months  must  be  allowed.  In  this  last  group  of  cases  marked  and  per- 
sistent overaction  may  and  should  be  foretold.  Bordier  and  Fraenkel  ^ 
insist  that  the  outward  and  upward  deviation  of  the  eye  when  the  patient 
tries  to  close  the  lids  is  proportionate  to  the  severity  of  the  nerve  injury, 
and  recovers  in  an  equal  ratio. 

Traumata  of  the  trunk  of  the  nerve  at  its  bony  exit,  even  severing  it, 
are  not  necessarily  of  grave  outlook,  as  union  and  regeneration  may  follow. 
Middle-ear  diseases  and  cranial  fractures  are  likely  to  heal  and  the  asso- 
ciated  palsy   to   pass   away.      Naturally,  the  prognosis  must  be  more 

1  "Sem.  Med.,"  Sept.,  1897. 


DISEASES  OF  THE  FACIAL  NERVE.  125 

guarded  in  these  conditions,  and  is  based  largely  upon  the  possil^ility  of 
their  reeoverv. 

Treatment. — The  tendeney  to  recovery  being  pronounced,  can  we 
shorten  the  duration  of  the  disability  ?  It  seems  probable.  If  the  case 
is  seen  early,  a  blister  or  leech  on  the  mastoid  may  reduce  the  congestion 
in  the  facial  canal.  Hot  applications  to  this  region  may  be  tried.  If 
not  thoroughly  and  persistently  used,  they  are  worse  than  useless  and 
later  on  quite  valueless.  When  the  case  is  developed  we  recognize  that 
the  lesion  of  the  trunk  shuts  off  trophic  and  motor  control.  The  indi- 
cation is  to  maintain  the  muscles  in  as  perfect  a  condition  as  possible 
until  the  way  for  nuclear  and  cortical  influence  is  reopened.  Further,  we 
should  strive  to  keep  the  muscles  as  responsive  as  possible  to  the  slight 
fraction  of  motor  control  that  remains,  or,  if  none  is  present,  to  the  weak 
and  inefficient  impulses  that  will  first  reach  them.  To  this  end  there 
are  three  things  to  do  :  (1)  Keep  the  face  in  place  by  having  the  patient 
constantly  push  the  cheek  and  mouth  to  their  proper  positions,  from 
which  every  smile  and  word  cause  them  to  be  dragged  by  the  sound 
muscles.  In  the  same  way  have  the  eyelids  rubbed  over  the  eyeball 
frequently,  and  at  night  a  compress  should  be  worn  to  keep  them  closed. 
This  has  the  additional  advantage  of  diminishing  and  often  of  prevent- 
ing conjunctivitis.  A  w^eakened  muscle  stretched  by  its  sound  antag- 
onists is  not  only  placed  at  a  mechanical  disadvantage,  but  actually  in- 
jured in  its  nutrition.  (2)  By  means  of  massage  and  hot  douches 
accelerate  and  improve  circulation,  and  thereby  the  nutrition  of  the 
affected  muscles.  (3)  By  electrical  stimulation  of  the  muscles,  com- 
menced from  the  first  day,  keep  up  their  responsiveness.  For  this 
purpose  a  galvanic  current  only  is  needed.  Faradism  to  contract  the 
muscles,  or  the  faradic  brush,  are  needless  and  painful.  Ordinarily  the 
best  plan  is  to  use  the  anode  at  the  motor  points  on  the  side  of  the  face 
and  to  daily  systematically  cause  the  muscles  to  gently  contract  six 
to  ten  times  by  anodal  closures.  This  pole  is  the  least  painful  and  the 
most  active  in  the  presence  of  degeneration. 

Traumatic  cases  are  to  be  treated  on  surgical  lines.  If  the  nerve- 
trunk  is  divided,  an  attempt  should  be  made  to  suture  it.  Breauvoine,^ 
in  the  manner  advocated  by  Faure  and  Furet,  reports  a  fair  success  fol- 
lowing the  establishment  of  an  anastomosis  between  a  diseased  facial 
and  the  spinal  accessory.  This  method  is  only  applicable  to  those  cases 
in  which  the  nerve  has  no  other  possibility  of  regeneration.  Tympanic, 
mastoid,  and  pharyngeal  trouble  wnll  require  topical  measures.  When 
the  neuritis  is  a  part  of  general  multiple  neuritis,  attention  is  directed  to 
the  toxic  cause.  Guided  by  the  rheumatic  idea,  such  remedies  as  the 
salicylates  have  been  recommended  and  may  be  tried  if  the  observer  can 
convince  himself  that  such  a  blood-state  exists.  Anemia  and  diminished 
physical  forces  from  any  general  cause  are  not  to  be  neglected.  Strychnin 
may  be  of  some  service,  acting  as  a  nuclear  stimulant  and  general  tonic. 

Nuclear  palsy  of  the  seventh  nerve  manifests  itself  by  the  same 
peripheral  motor  distribution  as  that  found  in  disease  of  the  trunk,  but 
lacks  the  gustatory,  auditory,  salivary,  and  sensory  disturbances.     The 
■    ^  "  Travaux  de  Neurologie  Chirurgicale, "  Jan.,  1901. 


126  DISEASES  OF  THE  CRANIAL  NERVES. 

muscles  degenerate  in  the  same  way  and  show  the  same  electrical  condi- 
tions. Almost  invariably  other  adjacent  cranial  nuclei  are  implicated. 
This  gives  rise  to  a  symptom  group  that  easily  differentiates  the  nuclear 
palsy  from  the  peripheral  form.  In  bulbar  palsy  tlie  facial  nucleus  is 
generally  invaded,  and  it  may  be  affected  in  polio-encephalitis  superior. 
The  nuclear  lesion  usually  produces  bilateral  symptoms.  The  pyramidal 
tracts  are  also  commonly  affected,  and  symptoms  in  the  trunk,  and  espe- 
cially in  the  extremities,  are  present. 

An  alternating  palsy  of  the  face  on  one  side  and  of  the  limbs  on  the 
other  is  due  to  a  pontine  lesion  (see  Fig.  44)  affecting  the  facial  fibers  before 
their  crossing  and  the  pyramidal  tract  above  its  medullary  decussation. 

Supranuclear  facial  palsy  results  from  any  lesion  destroying  the 
cortical  facial  centers  or  interrupting  the  communication  of  these  centers 
with  the  facial  nucleus.  Ordinary  capsular  hemorrhage  is,  therefore,  a 
frequent  cause  of  facial  palsy,  but  almost  invariably  at  the  same  time 
causes  hemiplegia.  In  these  supranuclear  palsies,  as  has  already  been 
indicated,  the  upper  portion  of  the  face  partially  or  entirely  escapes. 
Particularly  is  this  true  of  the  orbicularis  palpebrarum,  which  acts  volun- 
tarily. The  slight  weakness  that  is  present  is  often  shown  by  a  partial 
ptosis  completely  at  variance  with  the  constantly  open  eye  of  the  peripheral 
palsy,  but  the  eye  on  the  affected  side  usually  can  not  be  closed  as  vigor- 
ously as  the  other.  All  expressional  bilateral  movements  in  the  lower 
face  may  be  fairly  retained,  while  voluntary  control  is  practically  lost. 
In  the  peripheral  form  the  loss  is  equal  in  both  varieties  of  action. 

In  supranuclear  palsy  the  muscles  respond  actively  and  normally  to 
electricity,  and  their  trophic  condition  is  not  impaired.  In  other  words, 
the  lower  neuron  is  not  involved.  The  reflexes  are  present  for  the  same 
reason,  and  there  are  no  auditory,  secretory,  or  gustatory  symptoms.  A 
lesion  that  involves  the  optic  thalamus  may,  according  to  Bechterew, 
cause  loss  of  emotional  expression  on  the  opposite  side.  A  lateral  loss 
of  expressional  movements,  with  the  retention  of  voluntary  motion, 
therefore,  points  to  the  optic  thalamus,  which  contains  the  centers  for 
emotional  expression.  This  loss  has  been  found  associated  with  corre- 
sponding bilateral  hemianopsia  resulting  from  the  same  lesion. 


CHAPTER   VIII. 

DISEASES  OF  THE  EIGHTH  CRANIAL  NERVE. 
Anatomical  Considerations. — The  eighth  cranial  nerve  is  purely 
sensory.  It  is  made  up  of  two  portions  :  the  cochlear  branch,  which 
alone  conducts  sound  impressions,  and  the  vestibular  branch,  which  con- 
ducts space  sensations  from  the  semicircular  canals.  An  accessory  and, 
so  to  speak,  adventitious  portion  is  the  intermediate  nerve  of  Wrisberg, 
which  is  vasomotor  and  secretorv  in  function.      It  passes  to  the  facial 


DISEASES  OF  THE  EIGHTH  CRANIAL  NERVE. 


127 


nerve  and  finally  controls  salivation.  In  consistence  the  auditory  stem 
is  much  less  firm  than  the  facial.  It  follows  that  basilar  lesions  which 
aifect  the  seventh  almost  necessarily  involve  the  softer  auditory,  Avliich 
lies  beside  it.  But,  on  the  other  hand,  a  lesion  that  injures  the  auditory 
may  not  affect  the  more  resisting  facial  or  portio  dura. 

At  the  apparent  origin  of  the  auditory  trunk  the  internal  vestibular 
portion,  the  one  related  to  equilibration,  passes  backward  and  inward 
between  the  restiform  body  of  the  medulla  and  the  ascending  root  of  the 
trifacial  nerve,  to  terminate  in  two  groups  of  large  cells.  The  outer 
cochlear  portion,  the  true  auditory  root,  separates  from  the  vestibular 
root  near  the  apparent  origin,  and,  passing  outward  around  the  restiform 
body,  turns  inward  on  the  floor  of  the  fourth  ventricle  as  the  strise  acus- 
ticse,  which  dip  down  in  the  middle  line  to  the  nuclear  cells  of  Clarke. 
At  the  point  where  these  branches 
diverge  the  cochlear  root  presents 
a  group  of  cells,  for  the  vasomotor 
root  of  Wrisberg,  analogous  to  a 
posterior  root  ganglion.  Another 
group  of  cells,  the  acoustic  tuber- 
cle, often  of  large  size  in  animals, 
is  placed  just  outside  the  restiform 
body,  and  is  considered  a  pure 
auditory  nucleus.  The  higher 
relations  of  the  auditory  nuclei 
are  not  clearly  known,  nor  the 
exact  course  of  the  radiations  to 
the  cortex.  There  is  every  reason 
to  believe  that  the  vestibular  nu- 
clei are  in  relation  with  the  cere- 
bellum and  with  the  cerebrum. 
The  cochlear  nuclei  are  connected 
with  the  temporosphenoidal  cor- 
tex by  fibers  which  pass  through 
the  posterior  tliird  of  the  sensory 
division  of  the   internal  capsule. 

Each  ear  is  represented  on  both  sides  of  the  brain,  but  also  principally 
upon  the  opposite  side.  The  auditory  center  for  speech,  however,  in  right- 
handed  individuals  is  practically  confined  to  the  left  temporal  lobe,  the 
destruction  of  which  produces  word-deafness,  or  a  loss  of  spoken -word 
memories.  At  its  peripheral  termination  the  auditory  nerve  enters  the 
cribriform  opening  in  the  internal  meatus.  The  auditory  portion  is  dis- 
tributed to  the  cochlea  and  the  organ  of  Corti.  The  labvrinthian  portion 
is  distributed  to  the  vestibule  and  ampullae  of  the  semicircular  canals. 

Irritation  of  the  auditory  portion  of  the  eighth  nerve  is 
marked  by  auditory  hyperesthesia,  by  increased  acuteness  of  hearing  {hyper- 
acousis),  and  by  tinnitus.  It  must  be  understood  that  continued  irrita- 
tion of  the  auditory  apparatus  may  result  in  diminished  or  lost  function, 
just  as  overstimulation  of  any  tissue  or  organ  finally  produces  weakness 
and  involution.     It  follows  that  tinnitus,  for  example,  is  often  found  with 


Fig.  50. — Diagram  of  a  section  showing  tbie  ori- 
gin of  theeigbth  cranial  nerve.  V,  Vestibular  poi- 
tion  ;  C,  cochlear  portion  ;  W,  accessory  of  Wris- 
berg:  A,  accessory  nucleus  ;  T,  acoustic  tubercle; 
R,  restiform  body;  NC,  nucleus  of  Clarke  (after 
Brissaud). 


128  DISEASES  OF  THE   CRANIAL  NERVES. 

defective  hearing.  Hyperesthesia  is  frequently  present  in  excitable  and 
nervous  persons.  Migraine  and  all  forms  of  pain  often  render  the 
sufferer  more  sensitive  to  sudden  noises,  especially  of  high  pitch,  Ijut 
actual  hyperacousis  is  rare.  In  meningitis,  acute  mania,  and  under  the 
influence  of  some  stimulant  drugs,  such  as  alcohol,  opium,  anesthetics, 
Indian  hemp,  and  cafPein,  the  special  sense  of  hearing  is  at  times  actually 
exalted.  It  is  also  conceivable  that  an  irritant  lesion  of  the  auditory 
cortical  centers  might  give  rise  to  hyperacousis,  and  perhaps  this  is  also 
the  exj)lanation  of  some  hallucinations  of  hearing  and  sometimes  of  the 
rare  auditory  aurae  of  epilepsy.  The  increased  acuteness  of  hearing  for 
low  tones  in  facial  palsy  has  already  been  described. 

Irritation  or  disease  of  any  part  of  the  auditor^'  mechanism  is  likely 
to  produce  a  tinnitus  which  may  vary  widely  with  the  same  and  wdth 
different  cases.  It  may  resemble  hissing,  roaring,  buzzing,  singing,  tick- 
ing, throbbing,  the  sotmd  of  bells,  and  every  conceivable  monotonous 
noise.  Cerumen  or  foreign  bodies  in  the  external  meatus,  inflammation 
of  the  middle  ear.  Eustachian  occlusion,  the  throbbing  of  the  carotid  in 
its  canal  in  the  petron,  rhythmical  clonic  spasm  of  the  palate  and  orifice 
of  the  Eustachian  tube  in  hysterics,  meningeal  irritation  of  the  auditory 
nerve-trunk,  perforations  of  the  drum-head,  sclerosis  of  the  internal  ear, 
and  many  other  conditions  may  be  symptomized  by  a  tinnitus  aurium. 
A  tinnitus  is  present  in  some  cases  where  aurists  are  unable  to  detect  any 
peripheral  cause,  and  persists  practically  unchanged  throughout  life. 
As  a  rule,  a  continuous  tinnitus  interferes  with  hearing,  which  is  thereby 
diminished.  Fortunately,  it  is  frequently  tmilateral.  Certain  drugs, 
as  quinin  and  the  salicylates,  cause  tinnitus,  and  quinin  in  large  and 
repeated  doses  has  caused  permanent  deafness.  A  careful  aural  exami- 
nation is  needed  in  every  case  of  tinnitus,  and  the  reader  is  referred  to  the 
special  works  on  ear  diseases.  The  treatment  is  that  of  the  inciting 
condition. 

Paralysis  of  the  auditory  nerve  and  unilateral  deafness  may  fol- 
low a  cortical  lesion  involving  the  temporal  lobe.  Memories  of  heard 
speech  seem  to  be  stored  up  in  the  first  left  temporal  convolution.  A 
destructive  lesion  here  is  followed  by  ivord-deafness,  and  the  patient  no 
longer  understands  what  is  said,  though  he  clearly  hears  the  tones  of  the 
voice  and  all  sounds.  A  bilateral  lesion  of  the  temporal  cortex  causes 
complete  deafness.  Lesions  in  the  sensor^^  portion  of  the  capstile  may 
cause  a  unilateral  deafness  on  the  same  side  with  the  accompanying 
hemianesthesia.  A  unilateral  loss  or  diminution  of  hearing  in  the 
hemianesthesia  of  hysteria  is  not  uncommon.  It  may  come  on  suddenly 
and  disappear  in  the  same  manner.  The  presumption  is  that  the  cortex 
is  functionally  at  fault.  Complete — that  is,  bilateral — hysterical  deaf- 
ness is  seldom  encountered.  Xuclear  disease  of  the  eighth  nerve  is 
practically  unknown,  though  tumors  of  the  restiform  body  ^  and  the 
medulla  may  involve  the  cochlear  root. 

According  to  Virchow,  the  auditory  trtink,  most  frequently  rjf  all 
the    cranial    roots,  is   the  seat  of  new   growths.     Gouty  deposits    and 

^  Brissaud,  "  Le9ons  sur  les  Maladies  Xerveuses, "  Paris,  1895. 


DISEASES  OF  THE  EIGHTH  CRANIAL  NEBVE.  129 

hemorrhage  in  the  substance  of  the  root  have  Ijeen  found.  It  very  fre- 
quently is  involved  in  syphilitic  meningitis.  In  purulent  meningitis 
infection  may  travel  along  its  sheath  into  the  inner  ear  and  produce 
deafness  that  is  usually  permanent.  After  exposure  to  cold  the  eighth 
nerve  is  sometimes  subject  to  a  neuritis  similar  to  that  so  common  in  the 
facial,  which  may  or  may  not  be  associated  in  the  process.  The  condi- 
tion is  marked  by  diminished  or  complete  loss  of  hearing,  but  is  of 
favorable  prognosis.  Artisans  who  work  constantly  amid  loud  noises — as 
boilermakers,  tinsmiths,  and  other  metal  workers,  engine-drivers  and  fire- 
men on  railroads — often  present  a  partial  loss  of  hearing  that  may  pro- 
gressively increase.  They  sometimes  hear  better  in  the  accustomed  tur- 
moil than  in  quiet  places,  and  this  is  also  true,  but  much  less  commonly, 
of  ordinary  deafness.  The  auditory  nerve  may  be  injured  within  the 
petron  by  the  extension  of  inflammation  from  the  mastoid,  tympanum^  or 
pharynx,  and  by  basilar  fractures. 

Diagnosis. — The  first  thing  to  be  settled  in  a  case  of  deafness  is  the 
integrity  of  the  nerve.  If  the  nerve  is  at  fault,  the  condition  is  called 
nervous  07'  nerve  deafness.  When  there  are  no  basilar  symptoms,  in- 
volvement of  other  cranial  nerves,  bulbar  or  cerebral  indications,  and 
when  sounds  of  high  and  low  pitch  are  not  heard  through  the  air  or  by 
bone-conduction,  we  may  safely  locate  the  disease  in  the  nerve.  Rinne's 
test  (see  p.  64)  enables  us,  when  the  hearing  is  reduced,  to  fairly  deter- 
mine whether  the  difficulty  is  in  the  conducting  ap^Daratus  or  in  the  nerve. 
A  great  reduction  of  hearing,  in  which  air-conduction  remains  better 
than  bone-conduction,  but  in  which  both  are  deficient,  points  to  nervous 
deafness.  Lesions  within  the  brain-stem  and  in  the  temporal  lobe 
must  be  determined  by  the  association  of  symptoms  peculiar  to  these 
localities. 

Treatment. — In  the  treatment  of  nervous  deafness  we  have  first  to 
investigate  the  aural  apparatus  and  remove,  if  possible,  any  diseased  con- 
ditions that  may  be  present  All  acute  inflammatory  trouble  must 
subside  before  active  measures  are  instituted.  The  use,  then,  of  strych- 
nin, preferably  hypodermatically,  in  much  the  same  way  as  for  optic 
atrophy,  can  be  recommended.  Electricity  has  small  claims  to  notice, 
though  usually  suggested.  Unfortunately,  very  little  improvement  can 
be  expected.  Nerve  deafness  of  sudden  onset,  whether  due  to  syphilis, 
neuritis,  congestion,  or  hemorrhage  into  the  internal  ear,  is  sometimes 
favorably  modified  by  the  use  of  pilocarpin  in  full  doses  twice  daily  for 
a  week  or  two.^  Free  action  on  the  skin  is  to  be  produced.  In  these 
cases  quinin  and  the  salicylates  are  contraindicated,  though  sometimes 
of  value  in  the  chronic  forms. 

Irritation  of  the  Vestibular  Portion  of  the  Eighth  Nerve 
— Aural  Vertigo,  Meniere's  Disease. — The  function  of  the  semicircu- 
lar canals  is  still  subject  to  dispute.  It  can  at  least  be  accepted  that 
their  irritation  or  injury  may  cause  vertigo  and  disturbance  of  equili- 
bration. Recognition  of  relations  to  space  and  orientation  undoubtedly 
are  subserved  by  them  to  a  considerable  degree.      Their  innervation  is 

1  Dundas  Grant,  "Brit.  Med.  Jour.,"  Nov.  16,  1696. 


130 


DISEASES  OF  THE   CRANIAL   NERVES. 


by  the  vestibular  portion  of  the  eighth  cranial  nerve.  It  has  long  been 
recognized  that  disturbance  in  the  internal  or  middle  ear,  and  even  in  the 
external  meatus,  may  cause  not  only  tinnitus,  but  vertigo.  The  sudden 
inflation  of  the  drum  through  the  Eustachian  passage,  the  use  of  inter- 
rupted galvanic  currents  about  the  ear,  and  any  instrumentation  within 
the  tympanum  may  produce  giddiness.  The  only  essential  common 
character  of  all  these  causes  is  that  they  produce  irritation.  If  destruc- 
tion of  the  vestibular  branch  takes  place,  the  vertigo  usually  ceases. 
In  some  cases  of  aural  vertigo  due  to  middle-  or  internal-ear  disease,  ex- 
ternal objects  seem  always  to  revolve  to  the  right  or  to  the  left.  In 
other  instances  the  vertigo  is  subjective  and  the  patient  feels  as  if  revolved 
to  the  right  or  left  or  as  if  falling  forward,  backward,  or  downward. 
The  intensity  of  the  vertigo  varies  greatly.  It  may  be  quite  insignifi- 
cant or  it  may  be  so  pronounced  that  the  patient  holds  to  any  neighboring 
person  or  object,  staggers,  or  is  even  forcibly  projected  in  some  given 
direction.  The  attacks  are  usually  paroxysmal,  with  relative  freedom  in 
the  intervals.  In  the  form  described  by  Meniere  the  victim  is  struck 
down  as  if  shot,  there  may  be  unconsciousness  for  a  few  moments,  and 
the  patient  is  often  pale  and  covered  with  perspiration.  ISTausea  and 
vomiting  may  occur. 

The  great  majority  of  cases  of  aural  vertigo  occur  after  thirty  years 
of  age.  In  childhood  they  are  extremely  infrequent  and  rapidly  increase 
after  middle  life,  men  being  aifected  twice  as  frequently  as  women. 
Gout,  rheumatism,  and  the  sclerotic  changes  of  old  age  are  frequently  at 
the  bottom  of  the  symptoms.  These  may  act  directly  upon  the  laby- 
rinth or  indirectly  through  the  blood-supply  and  the  pressure  of  the 
endolymph.  A  vasomotor  element  is  given  considerable  importance  by 
some.  The  irritation  of  the  vestibular  filaments  is  usually  associated 
with  auditory  phenomena,  so  that  tinnitus  and  defective  hearing  are 
almost  invariably  present.  The  close  anatomical  relations  of  the  two 
portions  of  the  eighth  nerve  explain  this.  In  some  cases  the  labyrinth 
has  l^een  found  the  seat  of  hemorrhage  or  local  disease.  Sometimes  its 
epithelial  structure  is  degenerated.  Usually  disease  of  the  middle  and 
external  ear  is  Avanting  in  the  severest  cases,  while  decreased  hearing 
and  tinnitus  point  strongly  to  involvement  of  the  nerve  itself.  Some 
of  the  cases  of  the  Meniere  type  show  a  progressive  tendency,  with  fail- 
ing hearing,  first  in  one,  then  in  the  other  ear.  Complete  physical 
disability  through  the  vertigo  and  attacks  of  falling  may  ensue.  In 
some  instances  the  disease  remains  at  a  standstill  for  years,  and  may  even 
recede  and  hearing  be  restored.  Again,  when  hearing  is  lost  the  vertigi- 
nous attacks  may  cease.  Milder  varieties  run  various  courses,  depend- 
ing upon  their  causation  and  other  conditions. 

Diag-nosis  of  an  aural  vertigo  depends  in  practice  mainly  upon  the 
association  of  auditory  symjatoms.  Tinnitus  or  defective  hearing,  or 
both,  are  ordinarily  present.  The  defect  in  hearing,  as  tested  by  bone- 
conduction,  is  sometimes  unexpectedly  great,  the  ticking  of  a  watch 
when  placed  on  the  mastoid  being  inaudible.  If  the  vertigo  is  produced 
or  increased  by  changing  the  air-pressure  in  the  tympanum,  as  by  firmly 
pressing  the  tragus  into  the  meatus  or  by  Politzerization,  the  significance 


DISEASES  OF  THE  EIGHTH  CE AXIAL  NERVE.  131 

of  that  fact  is  great.  Frequently  the  attack  of  vertigo  is  associated  with 
an  intensification  of  the  tinnitus,  or  there  are  subjective  sounds  of  a  vio- 
lent character,  described  as  "  pistol  shots,"  "  something  breaking  in  the 
head,"  etc.  Sometimes  a  quick  movement  of  the  head  in  a  given  direc- 
tion produces  it.  This  apparently  has  relation  to  a  particular  semicir- 
cular canal,  which  is  mainly  or  alone  affected.  A  further  characteristic 
of  aural  vertigo  is  the  fact  that  the  subjective  or  oljjective  gyrations  are 
uniform  in  the  given  case,  or  the  stagger  or  falling  is  always  in  the 
same  direction.  In  epilepsy  we  not  infrequently  encounter  an  inde- 
scribable vertiginous  aura,  but  never  the  formulated  vertigo  of  aural 
disease.  The  epileptic  attack  is  usually  followed  by  mental  hebetude, 
which  is  lacking  in  aural  attacks,  where  the  vertigo  may  be  maintained 
for  a  long  time,  giving  rise  to  distressed  feelings,  vomiting,  and  col- 
lapse. The  seusorium  is  alw^ays  clear  in  aural  vertigo,  excepting  the 
initial  momentary  unconsciousness  of  the  severest  form,  or  in  the 
delirium  that  a  continuation  of  the  extremest  variety  may  produce  in 
very  rare  instances.  The  persistent  vomiting  usually  gives  rise  to  the 
idea  of  "  biliousness,"  and  frequently  a  brisk  cathartic,  relieving  all  the 
symptoms  of  vertigo,  is  supposed  to  confirm  the  idea  of  intestinal  or 
hepatic  derangement,  its  influence  on  cerebral  circulation  being  over- 
looked. Again,  the  sudden  onset  of  the  attacks  in  the  Meniere  form 
suggests  cerebral  disease  or  cardiac  attacks,  to  which  mistake  the  age  of 
the  patient  and  his  arterial  degeneracy  often  conduce.  The  repetition 
of  the  aural  attack  during  periods  of  rest,  and  even  during  sleep, 
with  absence  of  cardiac  and  cerebral  symptoms  in  the  meanwhile,  will 
correct  a  misconception  of  this  character. 

The  labyrinthine  variety  may  be  readily  confused  with  ocular  vertigo 
in  some  instances,  as  it  occasionally  gives  rise  to  nystagmus,  and  even 
has  produced  diplopia.  The  patients  sometimes  describe  oscillating 
movements  in  viewed  objects,  rapid  in  one  direction  with  slow  return, 
similar  to  the  nystagmic  movements  of  the  eyeballs.  The  mutual 
dependence  of  space  sensations  and  ocular  impressions  only  needs  to  be 
mentioned  to  explain  the  secondary  ocular  movements.  Ocular  vertigo 
ceases  the  moment  the  eyes  are  closed,  but  this  has.  no  effect  on  the  aural 
form.  Vertigo  is  associated  with  numerous  abdominal  disturbances, 
particularly  those  of  the  stomach,  liver,  and  small  intestine.  These 
forms  of  vertigo  are  usually  attended  by  indigestion  or  other  symptoms 
of  a  local  character,  and  the  vertigo  lacks  the  distinctive  gyratory  feature 
of  ear  trouble.  In  some  cases  of  aural  vertigo,  however,  the  patients 
complain  merely  of  "  dizziness,"  "  giddiness,"  or  "  swimming  "  sensa- 
tions. If  the  vestibule  alone  is  involved,  without  any  implication  of 
the  cochlea,  as  is  conceivable,  all  auditory  symptoms  default.  In  such 
cases  the  diagnosis  must  largely  depend  on  the  exclusion  of  other 
sources  of  vertigo. 

Treatment. — If  aural  vertigo  is  recognized  as  an  irritation  symptom, 
its  rational  treatment  will  depend  on  appreciating  and,  if  possible,  remov- 
ing the  basic  disease.  Cases  may  be  relieved  or  even  cured  by  Polit- 
zer's  inflation,  by  the  removal  of  cerumen,  or  by  the  correction  of  a 
pharyngeal  catarrh.     In  others  the  sclerotic  changes  in  the  labyrinth 


132  DISEASES  OF  THE  CRANIAL  NERVES. 

are  irremediable  and  treatment  is  directed  to  reducing  the  irritability  by 
bromids.  Charcot  strongly  recommended  in  the  Meniere  type  the  use 
of  quinin  in  large  doses,  but  others  have  not  had  his  success  with  that 
drug,  and  it  should  not  be  used  in  acute  cases.  He  even  advocated  the 
destruction  of  the  inner  ear,  producing  loss  of  hearing,  or,  in  other  words, 
a  removal  of  all  irritability  and  the  cessation  of  the  vertigo  at  once,  in  the 
same  way  that  sometimes  occurs  naturally.  Removal  of  the  malleus  and 
incus  and  mobilization  of  the  stapes  have  given  relief  in  many  instances 
and  may  be  advised  with  propriety,  especially  if  the  hearing  is  greatly  im- 
paired. Gout  and  arteriosclerosis,  middle-ear  disease,  and  lesions  of  the 
auditory  stem  must  be  treated  in  their  own  several  ways.  Electricity  is  of 
questionable  value,  though  it  is  asserted  by  some  that  the  positive  pole  over 
the  tragus  and  the  negative  on  the  back  of  the  neck,  with  a  current  of  three 
or  four  milliamperes  gradually  increased  from  zero,  continued  for  five 
minutes  and  then  decreased,  has  a  quieting  influence.  All  interruptions 
should  be  avoided.  Cases  of  acute  onset  are  sometimes  benefited  by  pilo- 
carpin,  as  in  nervous  deafness,  with  which  they  are  usually  combined. 


CHAPTER   IX. 

DISEASES  OF   THE  GLOSSOPHARYNGEAL,  VAGUS,  AND 
ACCESSORY  NERVES. 

Anatomical  Considerations. — The  glossopharyngeal  and  pneumo- 
gastric  nerves  and  the  bulbar  portion  of  the  spinal  accessory  should  be 
considered  as  one  mechanism.  Their  nuclei  in  the  medulla  are  practi- 
cally inseparable,  and  they  continuously  subserve  sensation  and  motion  for 
the  gastro-intestinal  tract  from  the  pharynx  to  the  duodenum.  In  addi- 
tion they  furnish  motor  filaments,  which  all  come  from  the  accessory 
portion,  to  the  lungs,  larynx,  and  heart.  They  are  visceral  nerves.  It 
is  to  be  kept  clearly  in  mind  that  the  spinal  portion  of  the  accessory  is 
a  pure  motor  nerve  to  the  skeletal  muscles  of  the  neck,  and  is  only 
locally  associated  with  the  pneumogastric.  The  interrelations  of  the 
glossopharyngeal-vagus-accessory  group  are  so  complex,  their  distribu- 
tion so  wide-spread,  and  their  indirect  disturbances  so  vague  that  they 
furnish  many  perplexities.  A  short  outline  of  the  glossopharyngeal  is 
first  given,  and  then  the  vagus  and  true  accessory  are  discussed  together. 


DISEASES  OF  THE  GLOSSOPHARYNGEAL  NERVE. 

The  ninth  cranial  nerve  is  still  a  source  of  anatomical  contention 
and  physiological  doubt.  In  consequence  its  diseased  conditions  are 
uncertain  and  obscure.  Practically,  in  man,  it  is  never  alone  diseased. 
If  its  relations  to  other  cranial  nerves  are  considered,  this  fact  is  readily 
understood.  Through  Jacobson's  nerve  it  forms,  with  the  sympathetic, 
the  tympanic  plexus,  whence  a  branch  connects  it  through  the  Vidian 


DISEASES  OF  THE   VAGUS  GROUP.  133 

with  the  facial  nerve,  and  another  branch  through  the  small  superficial 
petrosal  connects  it  witli  the  otic  ganglion.  It  is  connected  with  the  pneu- 
mogastric  at  the  petrous  ganglion  of  that  nerve,  and  also  in  the  pharyn- 
geal plexus.  Its  nuclei  are  intimately  associated  with  those  of  the  vagus 
and  accessory  nerves.  It  probably  subserves  sensation  in  the  upper 
part  of  the  pharynx  and  in  the  tympanum,  and  nausea  is  associated 
with  its  disturbance.  Probably  through  its  distribution  to  the  root  of 
the  tongue  it  peripherally  carries  the  fibers  of  the  special  sense  of  taste 
for  that  area,  but  these  are  not  embraced  in  its  root.  They  reach  the 
brain  by  a  circuitous  route,  probably  entering  the  petrous  ganglion  of 
the  glossopharyngeal  nerve  from  the  middle  branch  of  the  fifth  through 
the  tympanic  plexus  and  otic  ganglion.  It  seems  to  have  some  motor 
control  of  the  upper  portion  of  the  pharynx,  and,  perhaps,  of  the 
palate. 

Intracranial  disease  and  cranial  fractures  may  implicate  the  glosso- 
pharyngeal, causing  weakness  and  some  insensitiveness  in  the  upper 
pharynx  and  in  the  palate.  Its  nuclei  in  the  medulla  usually  suffer  in 
bulbar  palsy,  and  thus  are  produced,  at  least  in  part,  the  pharyngeal 
symptoms  of  that  disease. 


DISEASES   OF    THE   VAGUS   AND   BULBAR   PORTIONS   OF 
THE    ACCESSORY. 

Pharyngeal  Branches. — The  pharyngeal  branches  of  the  pneumo- 
gastric  follow  below  the  glossopharyngeal,  and  with  it  form  the  pharyngeal 
plexus,  supplying  motion  and  sensation  to  the  uppermost  portion  of  the 
intestinal  tube.  These  branches  are  paralyzed  by  nuclear  disease 
and  in  diphtheric  palsy,  but  seldom  otherwise.  Bulbar  involvement 
is  invariably  attended  by  symptoms  in  other  cranial  nerves.  The 
pharynx  is  more  or  less  insensitive  and  motionless.  The  pharyngeal 
reflex  is  lost.  Food  tends  to  accumulate  and  lodge  in  the  gullet  or 
overflows  into  the  larynx,  producing  spasmodic  cough  and  strangling. 
If  the  palate  at  the  same  time  is  weakened,  food  and  fluids  may  be 
forced  into  the  nasal  passages  and  regurgitate  through  the  nose.  A 
pharyngeal  spasm  furnishes  the  condition  commonly  noted  in  hysteria 
as  "  globus,"  or  esophagismus,  and  is  always  functional.  At  times  it 
may  be  mistaken  for  pharyngeal  paralysis,  or  the  difficulties  in  swallow- 
ing in  the  latter  may  be  attributed  to  spasm.  The  use  of  a  sound  will 
at  once  clear  the  doubt.  The  decided  pharyngeal  grasp  of  health  is  in- 
creased in  spasm  and  lost  in  paralysis.  Moreover,  spasm  is  temporary 
or  recurrent,  and  paralysis  is  continuous. 

Laryngeal  Branches. — The  larynx  is  innervated  by  two  branches 
of  the  pneumogastric  :  (1)  The  superior  laryngeal  governs  the  move- 
ments of  the  epiglottis  and  controls  tension  in  the  vocal  cords  through 
the  cricothyroid,  which  is  the  only  intrinsic  laryngeal  muscle  supplied 
by  this  nerve.  It  also  furnishes  sensation  to  the  larynx  above  the  vocal 
cords.  (2)  The  recurrent  laryngeal,  which  turns  about  the  aorta  on  the 
left  side  and  the  subclavian  artery  on  the  right  side,  supplies  sensation 


134 


DISEASES  OF  THE   CRANIAL  NERVES. 


to  the  trachea  and  to  the  larynx  below  the  vocal  cords.  It  controls  all 
the  intrinsic  laryngeal  muscles  except  the  cricothyroid.  These  muscles 
have  three  principal  vocal  actions  :  First,  to  draw  the  vocal  cords  tense ; 
second,  to  bring  them  close  together  ;  third,  to  draw  them  apart.  Though 
many  laryngeal  movements  are  highly  complex,  requiring  the  synergic 
action  of  several  groups  of  muscles,  it  is  well  to  remember  that  the 
chief  tensors  are  the  cricothyroids,  the  chief  abductoi^s  are  the  jDOsterior 
crico-arytenoids,  the  chief  adductors  are  the  lateral  crico-arytenoids.  In 
addition,  the  thyro-aryteuoids,  which  in  part  form  the  vocal  cords,  serve 
to  stiffen  them  and  make  their  apposition  uniform  and  effective.  By 
some  they  are  considered  tensors  and  by  others  laxors  of  the  cords,  and 
probably  serve  both  purposes. 

Laryngeal  paralyses  vary  in  degree  and  in  distribution.  They 
may  be  unilateral  or  bilateral,  2>artial  or  complete.  Further,  the  abduc- 
tors, the  adductors,  or  the  tensors  of  the  cords  may  be  alone  or  mainly 
involved.  Abductor  paralysis  is,  however,  by  far  the  most  common,  ^ 
even  when  the  lesion  falls  upon  the  recurrent.  A  full  knowledge  of  the 
anatomy  and  mechanism  of  the  larynx  is  required  to  understand  this 
subject,  and  the  use  of  the  laryngoscope  is  requisite  for  exact  diagnosis. 
The  following  table  is  given  to  show  the  common  varieties  of  laryngeal 
paralysis,  with  diagrams  of  the  corresponding  mirror  pictures,  which 
should  be  compared  with  the  normal  outlines  in  phonation,  respiration, 
and  death. 

Laryngeal  Paralyses. 


FoEM  OF  Paralysis. 

Muscles  Involved. 

Causes. 

Symptoms. 

Bilateral    adductor 

Both  lateral  crico- 

Anemia,     physical 

Voice  lost,   but   cough 

paralysis. 

arytenoids   and 

weakness,  hysteria. 

and  laugh  phonetic  ; 

(Fig.  54.) 

the  arytenoide- 

respiration  and  swal- 

us. 

lowing  normal  ;  no 
pain. 

Unilateral     adduc- 

One lateral  crico- 

Toxemia,  lead,    diph- 

Diminished voice  ; 

tor  paralysis. 

arytenoid. 

theria,   cerebral  dis- 

hoarseness;      cough- 

(Fig. 55.) 

ease,    s  m  a  1 1  -  p  0  X, 

ing,     laughing,     and 

syphilis,  phthisis. 

sneezing  diminished  ; 
difficulty  in  swallow- 
ing occasional. 

Bilateral   abductor 

Both     posterior 

Toxemia,    hysteria 

Voice  little  affected  for 

paralysis. 

crico-arytenoids. 

rarely,  injury  to  both 

ordinary  efforts  ;   re- 

(Fig. 56.; 

recurrent  nerves,   as 

spiration      impeded  ; 

by     enlarged     bron- 

extreme    inspiratory 

chial     glands  ;     dis- 

stridor, with  free  ex- 

eased   thyroid,    new 

piration. 

growths  in  the  neck. 

etc. 

Unilateral     abduc- 

One posterior 

Stretching  or  injury  to 

Voice    harsh,    impure, 

tor  paralysis. 

crico-arytenoid. 

one  recurrent  nerve. 

and  hoarse  ;  some  in- 

(Figs. 57  and  58.) 

as  by  aortic  aneur- 
ysm, and   the  same 
causes  as  in  the  bi- 
lateral form,  acting 
on  one  side  only. 

spiratory  stridor. 

iSemon,  "Brit.  Med.  Jour.,"  Jan.  1,  1898. 


DISEASES   OF   THE   VAGUS  GROUP. 


135 


Laryngeal  Paralyses. — {Continued.) 


Form  of  Paralysis,  i  Muscles  Involved. 


Bilateral    paraly.sis  [  Criootliyioids. 
of  tensors. 


Causes. 


Paralysis     of      the 

cords  proper. 
(Figs.  59  and  60.) 


Colds;  voice  straining; 
diphtheria. 


Thyro-aryteuoids. 


Overexertion,  hysteria. 


Symptoms. 


Hoarseness ;     inability 
to  take  high  notes. 


Loss  of  falsetto  notes 
and  uncertainty  of 
voice-p roductiou  ; 
usuallj'  attended  by 
some  adductor  pare- 
sis, and  frequently  by 
loss  of  power  of  the 
arytenoideus. 


Fig.  51.— Normal  phouation. 


Fig.  53. — Normal  cadaveric 
position. 


Fig.  54. — Bilateral  adduc- 
tor paralysis.  Attempted  pho- 
nation. 


Fig.  55.— Left  adductor 
paralysis.  Attempted  pho- 
nation. 


Fig.   56  — Bilateral   abductor 
paralysis.  Deep  inspiration. 


Fig.  .57.— Left  abductor  paraly- 
sis. Deep  inspiration.  Affected  cord 
in  cadaveric  position. 


Fig.  58.— Left  abductor  paraly- 
sis. Plionation.  Affected  cord  in 
cadaveric  position.  Right  cord 
crossing  median  line. 


Fig.  59.- 


-Bilateral  thyro-arytenoid 
paralysis. 


Fig.  60.— Bilateral  thyro-aryte- 
noid paralysis  and  paralysis  of  ary- 
teuoideus,  giving  an  hour-glass  open- 
ing. 


136  DISEASES  OF  THE   CEANIAL  NERVES. 

In  complete  bilateral  paralysis  of  the  larynx,  such  as  results  from 
injury  to  both  recurrent  nerves,  the  vocal  cords  occupy  the  cadaveric 
position,  and  are  motionless.  There  is  no  voice,  and  coughing  and 
sneezing  are  impossible.  Deep  inspiration  develops  stridor.  If  the 
complete  paralysis  is  unilateral,  the  motionless,  paralyzed  cord  occupies 
the  cadaveric  position,  while  its  fellow  moves  actively  in  phonation  and 
respiration,  even  passing  the  middle  line  in  adduction.  The  voice  is 
low-pitched  and  hoarse,  cough  is  absent,  and  stridor  only  appears  on 
very  deep  inspiratory  efforts. 

The  treatment  of  laryngeal  palsies  depends  on  that  of  the  causa- 
tive condition.  Laryngeal  palsies  due  to  surgical  injury  of  the  nerve, 
as  by  the  inclusion  of  the  pneumogastric  in  ligation  of  the  carotid,  or 
its  division  in  operations  on  the  thyroid,  have  occurred.  Here  the 
immediate  danger  is  to  the  heart.  In  the  diphtheric  foniis  and  in  other 
toxic  varieties,  the  use  of  electricity  is  recommended.  To  be  of  any 
value  it  must  be  applied  with  the  intralaryngeal  electrode  and  requires 
special  skill.  The  neuritic  forms  of  laryngeal  palsy  are  of  fair  prog- 
nosis, with  or  without  treatment,  if  the  patient  survives  the  early  effects 
of  the  toxemia.     The  nuclear  varieties  are  practically  irremediable. 

Anesthesia  of  the  larynx  is  occasioned  by  interference  with  the 
superior  laryngeal  nerve,  which  supplies  sensation  above  the  vocal  cords. 
It  may  be  unilateral  or  double- sided.  In  hemianesthesia  from  cerebral 
lesions  and  hysteria  it  may  be  unilaterally  present,  with  preserved  re- 
flexes, which  are  lost  in  nuclear  or  trunkal  disease  of  the  pneumogastric. 
Hysterical  adductor  paralysis  with  aphonia  commonly  presents  a  loss  of 
sensation  at  the  laryngeal  inlet. 

Laryngeal  spasm  is  due  to  irritation  of  the  recurrent  larj^ngeal 
nerve  or  to  reflex  causes  mainly  arising  in  the  pneumogastric  periphery 
and  acting  through  this  branch.  With  the  reflex  action  that  protects  the 
larynx  from  the  entrance  of  foreign  bodies  we  are  familiar.  This  may 
be  intensified  by  local  irritation,  as  in  catarrhal  laryngitis,  especially  in 
children,  giving  rise  to  croupy  cough  and  attacks  of  croup  at  night. 
The  laryngismus  stridulus  of  rickets,  or  tetany,  or  enlarged  thymus,  or 
in  goitrous,  pubescent  girls,  is  due  to  adductor  spasm.  It  may  be  de- 
pendent upon  a  long  uvula,  enlargement  of  the  pharyngeal  tonsil,  or 
nasal  conditions  sufficient  to  provoke  the  reflex.  Indigestion,  especially 
in  children,  and  more  particularly  in  ill-nourished  children,  is  a  common 
source  of  reflex  laryngeal  spasm.  It  may,  in  adults,  be  the  result  of 
injuries  to  the  nerve.  It  not  uncommonly  is  the  neurotic  equivalent 
of  asthma  or  migraine,  with  which  it  may  alternate.  The  epileptic  cry 
is  due  to  a  laryngeal  and  thoracic  spasm.  There  is  a  variety  that  is 
sometimes  called  laryngeal  epilepsy.  It  may  be  an  element  in  hys- 
terical convulsions,  or  the  only  representative  of  such  attacks. 

A  partial  laryngeal  spasm  in  severe  stammering  sometimes  induces  an 
explosive  utterance  attended  by  evident  respiratory  difficulty.  From 
overuse  of  the  voice,  especially  by  bad  methods,  a  spasmodic  neurosis 
of  the  larynx  similar  to  a  writer's  cramp  may  be  set  up.  Speech  at  first 
is  fairly  uttered,  but  the  unbalanced  and  spasmodic  action  of  the  vocal 
apparatus  promptly  manifests  itself  by  loss  of  modulation  and  by  ex- 


DISEASES  OF  THE   VAGUS  GROUP.  137 

plosive  enunciation.  Laryngeal  spasm  is  marked  by  a  sudden  onset  and 
often  comes  on  during  sleep.  There  is  every  evidence  of  dyspnea,  and 
the  marked  stridor,  both  on  inspiration  and  expiration,  serves  to  distin- 
guish it  from  abductor  palsy  of  the  larynx.  The  attack  is  very  short, 
lasting;  but  a  few  seconds  at  most. 

A  number  of  spasmodic  nervous  coughs  are  described,  such  as  the 
barking,  explosive,  incessant  cough  of  hysteria,  the  metallic  ovarian 
cough  of  young  girls,  and  the  barking  cough  of  pubescent  and  mastur- 
bating boys.  In  all  of  these  conditions  there  is  a  strong  neurosal  ele- 
ment that  must  be  given  first  importance  in  etiology  and  treatment. 

Pulmonary  Branches. — The  pulmonary  branches  of  the  pueumo- 
gastrie  with  branches  from  the  sympathetic  ganglia  accompany  the 
bronchi  into  the  lungs.  It  is  probable  that  the  vagus  supplies  motor 
filaments  to  the  bronchial  muscles  of  unstriped  fiber.  The  nutrition  of 
the  lungs  also  seems  to  be  under  their  control,  though  the  vasomotor 
supply  conies  through  the  sympathetic.  It  has  been  noted  in  animals 
that  death,  after  division  of  the  vagus,  is  due  to  pneumonia.  The  prin- 
cipal pneumogastric  pulmonary  derangements  are  bronchial  asthma  and 
protracted  hiccup,  which  in  some  rare  cases  are  interchangeable. 

Bronchial  or  Spasmodic  Asthma. — The  early  contention  of 
Trousseau,  Williams,  and  others,  that  there  occurs  a  spasm  of  the  bron- 
chioles in  asthma,  is  confirmed  by  Bert  and  proven  by  Biermer.  It  is 
accompanied  by  turgescence  of  the  mucosa  and  a  characteristic  exudate 
of  mucin  in  the  form  of  spirals,  which  often  contain  polygonal 
crystals,  by  Leyden  supposed  to  be  causal  of  the  attack.  There  can  be 
no  doubt  that  this  neurosis  is  common  in  some  families  by  direct 
inheritance  for  generations.  In  rare  cases  in  the  same  patient  it  has 
alternated  with  migraine  or  attacks  of  hiccup,  and  even  with  epilepsy. 
In  other  instances,  again,  in  neurotic  stock  it  has  taken  the  place  of 
graver  neuroses  and  of  the  psychoses  in  members  of  the  same  or  suc- 
ceeding generations.  AVhile  it  may  originate  apparently  without  any 
cause  extraneous  to  the  individual,  in  many  cases  every  attack  can  be 
traced  to  certain  irritant  fiictors,  such  as  the  inhalation  of  dust,  the 
pollen  of  certain  plants,  or  a  certain  odor.  It  has  been  shown  by  Hack 
and  confirmed  by  many  others  that  nasal  conditions  may  incite  and 
prolong  the  attacks,  Avhich  do  not  appear  when  the  source  of  nasal  reflex 
irritation  is  removed.  In  the  same  way  intestinal  and  genital  disturb- 
ances may,  in  individual  cases,  be  the  starting-point  of  the  attacks. 
Spasmodic  asthma  is  also  associated  with  defective  renal  activity  and 
the  various  acute  and  chronic  uremias.  Its  relation  to  gout,  rheuma- 
tism, and  plumbism  is  not  less  clear.  In  every  instance  a  potential 
state  must  be  present,  and  these  peripheral  or  endogenous  excitements 
merely  fire  the  train  resulting  in  the  nervous  explosion  of  the  asthmatic 
attack. 

Spasmodic  asthma,  except  in  the  form  of  hay  asthma,  rarely  appears 
before  adult  age.  It  is  more  frequent  in  men  than  in  women,  a  fact 
that  is  to  be  explained  by  their  greater  exposure  to  the  inclemencies  of 
the  weather.  There  is  no  doubt  that  laryngeal  and  bronchial  irrita- 
tion from  such  cause  may  be  provocative  of  the  asthmatic  attack.     In 


138  DISEASES  OF  THE   CRANIAL  NERVES. 

long-standing  cases  the  secondary  pulmonary  emphysema  and  chronic 
bronchitis  constantly  keep  the  spasmodic  features  within  striking  distance. 

Symptoms. — Asthmatic  attacks  come  on,  as  a  rule,  with  considerable 
suddenness,  and  are  marked  by  intervals  of  practically  complete  relief. 
Except  in  the  hay-asthma  varieties,  the  ]>atient  most  frequently  is  awak- 
ened from  sleep  by  distressed  breathing  that  rapidly  grows  worse.  Inspir- 
ation and  expiration  are  both  difficult, and  expiration  is  greatly  lengthened. 
As  the  dyspnea  increases  and  persists  the  face  is  suffused  and  the  lips  be- 
come bluish.  The  patient  is  covered  with  perspiration  and  evidences  his 
distress  only  too  plainly  by  the  laboring  chest,  the  anxious  and  drawn  face, 
and  the  noisy,  blowing,  wheezy  respiration.  The  thorax  is  rounded,  the 
diaphragm  depressed,  and  its  excursions  diminished  ;  the  muscles  at  the 
neck  are  in  strong  relief  in  the  attempt  to  increase  the  respiratory  action. 
The  patient  calls  for  air.  He  often  props  himself  up  in  bed  or  on  chairs 
and  other  objects  to  raise  and  fix  the  shoulders,  thereby  increasing  the 
action  of  the  adventitious  respiratory  muscles.  At  last,  when  he  seems 
unable  to  endure  longer,  the  spasmodic  breathing  lessens,  relief  is  expe- 
rienced, and  he  may  fall  into  the  sound  sleep  of  exhaustion,  perhaps  to 
be  again  awakened  after  a  few  hours  by  a  repetition  of  the  attack.  The 
first  attacks  are  usually  mild,  and  only  attain  the  indicated  intensity  after 
a  number  of  asthmatic  bouts.  In  the  advanced  and  ancient  cases  a  small 
degree  of  spasm  may  be  continually  present,  manifesting  itself  upon 
the  slightest  exertion  or  exposure.  During  the  attacks  the  physical 
signs  are  very  slight.  Roughened  broncliial  breathing  and  moist  rales 
are  noted.  At  first  hard  coughing  brings  up  a  little  mucus,  but  toward 
the  end  of  the  attack  a  considerable  quantity  is  frequently  ejected  with 
apparent  ease  and  relief. 

Treatment. — In  the  management  of  asthma  the  neurotic  condition 
should  ever  be  kept  in  mind.  General  measures  to  build  up  the  tone 
and  stability  of  the  nervous  system  are  essential.  Outdoor  life  and 
moderate  exercises,  hydrotherapy,  tonics,  correct  habits,  and  hygienic 
measures  are  indicated.  The  inciting  element  must  be  most  carefully 
and  persistently  sought.  If  this  can  be  recognized  early,  its  removal 
gives  hope  of  complete  immunity  from  the  recurring  attacks  that  in  so 
many  cases  make  life  Avretched.  It  is  probable  that  every  repetition  of 
the  asthmatic  storm  reduces  the  power  of  resistance  and  serves  to  estab- 
lish an  increasing  asthmatic  habit.  When  this  has  been  formed,  and 
bronchitis  with  emphysema  induced,  a  cure  can  not  reasonably  be 
expected.  Regarding  drugs,  the  iodid  of  potassium  has  a  deserved  repu- 
tation. It  is  particularly  indicated  in  the  chronic  and  uremic  forms  of 
asthma.  Strychnin  in  large  and  increasing  doses  gives  occasional  aid.  It 
may  be  given  in  doses  increasing  to  -^-^  of  a  grain  three  times  a  day,  if 
well  tolerated.  The  correction  of  peripheral  states  in  the  nose,  intes- 
tines, kidneys,  genitals,  etc.,  has  been  sufficiently  urged.  Climatic 
changes  are  of  importance,  but  one  can  never  predict  the  result  of  this 
measure.  In  every  case  it  is  experimental.  One  patient  will  have 
complete  immunity  in  a  locality  that  is  unbearable  to  another  apparently 
similar  case.  In  hay  asthma  a  patient  may  secure  relief  one  year  at 
some  resort  and  the  following  season  find  his  journey  futile. 


DISEASES  OF  THE   VAGUS  GROUP.  139 

The  attack  can  often  be  cnt  sliort  by  the  nse  of  any  one  of  a  number 
of  sedatives.  Inhalations  of  nitrite  of  amyl  uv  clilorcjform  may  ^\\e 
almost  instiint  relief.  Fumigations  with  niter  and  stramonium  or  some 
similar  solanaceous  plant  are  much  in  favor.  Cigarettes  and  pastilles  of 
such  materials  are  prepared  by  the  trade.  The  smoke  must  l)e  deeply 
and  freely  inhaled.  A  dose  of  spirit  of  chloroform  or  of  sulphuric 
ether  is  often  productive  of  temporary  benefit.  Inhalation  of  steam 
charged  with  camphor  is  a  ready  and  sometimes  efficient  measure. 
This  is  furnished  by  dropping  a  dram  of  any  camphor  preparation 
into  a  pint  of  boiling  water  in  a  small  pitcher,  over  which  the  patient 
holds  his  face. 

Hiccup  is  usually  referred  to  the  phrenic  nerve,  the  diaphrag- 
matic action  being  considered  its  most  important  feature.  It  appears, 
however,  to  be  a  respiratory  difficulty,  and  is  undoubtedly  associated 
with  the  respiratory  centers.  Not  only  does  the  diaphragm  act  spas- 
modically, but  there  is  a  general  thoracic  inspiratory  movement  and  a 
laryngeal  fixation  or  spasm,  giving  rise  to  the  peculiar  inspiratory  sound 
with  which  all  are  familiar.  In  some  cases  there  are  protracted  attacks 
of  hiccup  that  are  neurotic  equivalents  for  asthma  or  other  neurotic 
disturbance.  Such  attacks  may  also  occur  independently.  Injury  to 
the  phrenic  or  to  the  pneumogastric,  or  even  to  the  superior  laryngeal 
nerve,  has  occasioned  it.  In  hysteria  it  is  not  a  rare  manifestation,  and 
may  last  for  weeks  during  the  waking  hours.  It  may  be  dependent 
upon  distant  reflex  irritation  in  the  intestine  or  genito-urinary  tract,  or 
upon  affections  of  the  larynx  and  pharynx.  In  all  conditions  when  the 
respiratory  centers  are  intoxicated  or  depressed,  as  in  uremia,  syncope, 
suffocation,  after  hemorrhage,  in  cholera,  etc.,  hiccup  may  appear,  and 
is  of  serious  significance. 

The  treatment  of  a  protracted  attack  of  hiccup  is  etiological. 
Some  rebellious  cases  have  been  promptly  terminated  by  inducing  sneez- 
ing, which  is  the  exact  opposite  of  singultus.  Sedatives  of  all  sorts 
have  at  times  seemed  useful,  and  musk  is  especially  recommended. 
Faradism  to  the  phrenic  nerve  and  diaphragm  has  served  a  good  pur- 
pose. In  the  hysterical  cases  often  nothing  short  of  complete  isolation 
and  the  most  thorough  management  of  the  hysterical  condition  will 
avail. 

Cardiac  Branches. — The  cardiac  plexus  is  made  up  of  accelerator 
branches  from  the  sympathetic,  and  of  the  superior  and  inferior  cardiac 
branches  of  the  vagus,  respectively  given  off  from  its  cervical  and 
thoracic  portions.  The  vagus  filaments  are  known  to  inhibit  the 
heart's  action,  and  are  supposed  to  subserve  sensation,  being  afferent 
in  this  function.  Whether  or  not  they  contain  trophic  fibers  for  the 
heart  is  still  disputed.  Affections  of  the  cardiac  branches  of  the 
pneumogastric,  or  neuroses  acting  through  these  branches,  modify  their 
inhibitory  function,  or  give  rise  to  cardiac  sensations,  or  both. 

Tachycardia  is  undue  rapidity  of  the  heart's  action.  It  may  be 
temporary  or  permanent,  and  is  due  to  the  increased  accelerator  sympa- 
thetic influence  or  to  decreased  vagus  inhibitory  control,  or  to  both  act- 
ing together.     Some  individuals  have  naturally  a  quick  heart.     The  term 


140  DISEASES  OF  TEE   CRANIAL  NEEVES. 

tachycardia  is  here  limited  to  an  acquired  rapidity  aside  from  that  of 
exertion,  that  associated  with  elevation  of  body-heat,  hemorrhage  and 
weak  heart,  convalescence  from  acute  illness,  etc.  It  may  be  temporary 
or  permanent,  but  usually  occurs  in  attacks  or  paroxysms  in  which  the 
patient  feels  distressed  and  anxious,  often  presents  flushings  and  other 
vasomotor  disturbance,  and  the  pulse  may  be  found  beating  at  120  or 
even  attain  a  rate  of  300  or  more  a  minute.  Of  this  the  patient  may 
be  unconscious,  in  which  respect  it  differs  from  palpitation,  an  essentially 
subjective  sensation.  The  attack  often  terminates  rather  suddenly,  and 
may  be  followed  by  free  sweating,  copious  urination,  or  even  by  diarrhea. 
Nothnagel  gives  the  following  distinctions  between  accelerator  irritation 
and  vagus  paralysis  :  Great  increase  in  frequency  of  pulse,  with  weak 
heart-sounds  and  other  disturbances  in  the  pneumogastric  area,  as 
aphonia,  hoarseness,  gastralgia,  or  cardiac  pain,  refer  to  the  vagus. 
Strong  heart-sounds  and  impulse,  full  peripheral  vessels,  and  vasomotor 
storms  indicate  accelerator  disturbance.  AYhittakeri  says  the  increase 
to  120  beats  implies  irritation  of  the  sympathetic;  from  120  to  180 
beats,  paralysis  of  the  vagus;  above  180,  the  combined  elfect  of  both 
causes. 

Tachycardia  may  be  due  (1)  to  disease  of  the  heart  and  blood- 
vessels, (2)  to  injury  of  the  vagus  trunk  or  nucleus,  (3)  to  toxic  causes, — 
alcohol,  nicotin,  coffee,  and  atropin, — (4)  to  a  reflex  from  any  viscus, 
especially  those  in  the  pneumogastric  field,  and  (5)  to  many  neuroses,  as 
Graves's  disease,  hysteria,  and  neurasthenia.  The  prognosis  and  treat- 
ment necessarily  depend  on  the  causation.  The  purely  neurotic  forms 
are  difficult  to  manage,  though  not  of  serious  import  so  far  as  life  is  con- 
cerned. 

Cardiac  palpitation  is  sometimes  a  purely  nervous  condition,  a 
vagus  neurosis.  Hysterics  and  neurasthenics  are  often  much  troubled 
by  this  rapid  heart-action,  of  which  they  are  perfectly  aware.  It  may 
come  on  independently  of  an}"  assignable  cause,  as  during  moments  of 
rest,  or  even  during  sleep,  though  here  the  influence  of  some  dis- 
tressing dream  can  not  be  excluded.  It  lacks  the  anxiety  and  often 
associated  heart-pain  of  tachycardia  and  angina  pectoris,  but  is  often 
attended  by  tinnitus,  vertigo,  and  a  feeling  of  faintness.  All  source 
of  c^ardiac  disturbance  must  be  excluded  before  admitting  this  form  of 
vagus  disturbance. 

Unless  it  is  merely  symptomatic,  the  etiology  is  obscure  and  its  treat- 
ment difficult.  Sedatives  and  narcotics,  with  local  applications  of  heat 
or  cold  over  the  precordium  and  the  administration  of  diffusible  stimu- 
lants, may  be  employed  to  arrest  the  attack. 

Bradycardia  is  the  opposite  of  tachycardia.  A  slow  pulse  is 
apparently  normal  to  many  individuals  and  is  not  associated  with  any  dis- 
tress or  difficulty.  Such  instances,  in  which  the  heart-beats  are  twenty, 
thirty,  or  forty  a  minute,  are  on  record.  The  term  is  here  limited  to  an 
acquired  slow  beat  that  may  be  permanent,  temporary,  or  paroxysmal. 
It  is  sometimes  noted  in  cervical  myelitis  or  injuries  to  the  cord  in  this 

1  "  Twentieth  Century  Practice,"  vol.  iv. 


DISEASES  OF   THE    VAGUS  GROUP.  141 

region.  Cerebral  conditions  marked  by  pressure,  as  hemorrhage,  hydro- 
cephalus, and  tumor,  reduce  the  ])ulse-rate,  and  it  is  often  slow  in  meningitis. 
The  actions  of  narcotics,  biliary  poisoning,  and  uremia  only  need  to  be 
mentioned.  Many  infective  diseases,  such  as  rheumatism,  puerperal  fever, 
typhoid,  and  diplitheria,  may  produce  bradycardia  of  a  persisting  sort,  or 
may  be  followed  by  it.  They  probably,  at  times,  set  up  a  vagus  neuritis. 
Organic  processes  acting  on  the  pneumogastric  cardiac  inhibitory  center,  or 
on  its  cardiac  fibers,  may  retard  the  heart  by  the  irritant  stimulation  of  the 
inhibitory  function.  Disease  of  the  heart-muscle  itself,  as  in  fatty  heart 
and  coronary  sclerosis,  may  produce  bradycardia,  and  seems  to  act  by  irri- 
tation of  the  terminal  filaments  of  the  vagus.  The  nuclear  variety  is 
often  associated  with  arteriosclerotic  changes  in  the  medulla. 

Bradycardia  is  usually  attended  by  syncopic  disturbance,  which  has 
not  rarely  been  mistaken  for  epilepsy.  The  paroxysmal  form  is  often 
marked  by  anxiety,  unrest,  and  distress  in  the  precordial  region.  Car- 
diac angina  and  nausea,  or  vomiting,  may  ensue.  Convulsions  are  some- 
times noted.  When  the  vagus  trunk  is  affected,  other  motor  symptoms 
may  indicate  it,  such  as  aphonia,  hoarseness,  stridor,  and  choking.  The 
diagnosis  of  bradycardia  is  not  difficult,  but  the  heart-beat  should  never 
be  determined  by  the  radial  pulse.  The  treatment  and  prognosis  de- 
pend on  the  causal  condition. 

Angina  pectoris  is  an  affection  of  the  vagus  marked  by  paroxysms 
of  agonizing  pain  in  the  region  of  the  heart,  which  radiates  usually  to 
the  left  shoulder  and  arm,  and  is  attended  by  a  sensation  of  impending 
death.  By  some  it  is  called  true  angina  pectoris  when  dependent,  as  is 
usually  the  case,  upon  organic  heart  disease,  in  distinction  from  false  or 
pseudo-angina,  in  which  no  anatomical  changes  are  discoverable.  There 
is  a  strong  probability  that  the  sympathetic  fibers  participate  in  the  storm, 
but  the  essential  element  is  the  vagus  neuralgia.  The  attacks  are  some- 
times induced  by  exertion  or  emotion,  but  may  rouse  the  patient  from  a 
sound  sleep.  Rarely  occurring  in  children,  it  is  much  more  common  in 
male  adults  and  in  the  latter  half  of  life,  when  the  arterial  changes  and 
cardiac  myopathies  are  commonly  found.  It  may  occur  independently 
of  such  organic  changes  in  neurotic  individuals,  and  is  encountered  in 
hysteria,  subsiding  with  that  neurosis  or  suddenly  ceasing  upon  the 
appearance  of  other  hysterical  manifestations. 

The  pain  varies  in  character  and  severity.  Its  usual  radiation  to 
the  brachial  plexus  may  be  replaced  by  epigastric,  ilioscrotal,  vesical, 
and  even  sciatic  pain,  ordinarily  on  the  left  side.  The  feeling  of  im- 
pending death,  however,  is  an  essential  symptom.  The  pulse  may  be 
unchanged  even  in  the  presence  of  the  most  excruciating  pain  and  the 
most  frightful  anxiety,  or,  rarely,  the  heart  may  present  tachycardia  or 
bradycardia.  The  patient  is  often  bathed  in  perspiration,  and  in  rare 
cases  other  pneumogastric  conditions,  as  asthma,  laryngeal  spasm,  or 
esophagismus,  may  attend  the  anginal  attack.  The  attack  lasts  from  a 
few  minutes  to  an  hour,  and  usually  subsides  as  suddenly  as  it  com- 
menced. The  patient  feels  considerably  shaken  up  and  rather  languid 
for  a  time,  but  in  the  intervals  of  the  attacks  may  be  completely  free 


142  DISEASES  OF  THE   CE AXIAL   NEEVES. 

from  all  distress  aside  from  that  attributable  to  organic  cardiac  effects 
and  the  apprehension  of  another  attack. 

The  prognosis  depends  on  the  condition  of  the  heart.  If  it  is  not 
organically  diseased,  the  angina  does  not  end  fatally,  and  even  cases  of 
organic  heart  disease  seldom  die  in  anginal  attacks.  The  treatment 
of  the  attack  is  antispasmodic.  Amyl  nitrite  and  trinitrin  hold  the 
first  place  ;  chloroform  by  inhalation,  the  application  of  heat  or  cold  to 
the  precordium,  whisky,  and  other  similar  measures  are  of  some  value. 
In  the  intervals  treatment  is  directed  to  the  condition  of  the  heart  or  to 
the  neurosis,  or  to  both. 

Gastric  Branches. — The  pneumogastric  supplies  motor  branches 
to  the  stomach,  but  only  in  part  innervates  the  muscular  coat  of  that 
viscus.  Certain  gastric  movements,  such  as  sobbing  and  vomiting,  un- 
doubtedly depend  upon  its  motor  filaments.  Vomiting  is  reflexly  pro- 
duced through  its  gastric  sensory  fibers,  as  well  as  directly  by  intra- 
cranial disease  or  irritation  of  its  trunk.  Vomiting  due  to  intracranial 
disease,  or  that  provoked  by  irritating  the  vagus  trunk  and  sometimes 
that  due  to  irritation  of  its  stomach  branches  by  organic  disease,  is 
peculiarly  rapid,  projectile,  and,  as  a  rule,  unattended  by  nausea.  The 
vagus  probably  conveys  the  sensations  of  hunger,  at  least  they  have  been 
completely  destroyed  by  bilateral  lesions  of  these  nerves.  Ravenous 
appetite  for  food  and  the  peculiar  subjective  gastric  sensations  of  dys- 
pepsia, organic  disease  of  the  stomach,  and  some  neurotic  and  psychical 
states  are  properly  attributable  to  the  central  or  peripheral  conditions 
of  the  pneumogastric  nerve. 

Gastralgia,  or  Gastrodynia. — Aside  from  the  stomach-pain  of 
organic  gastric  disease,  fermentation,  and  dyspepsia,  there  is  a  neurosis 
of  the  stomach  marked  by  sudden  pain  in  this  viscus,  to  which  the  name 
nervous  gastralgia  is  given  by  Ewald.  It  is  not  attended  by  the  symp- 
toms of  disturbed  digestion,  and  the  stomach  contents  at  such  times,  as 
well  as  between  the  attacks,  show  nothing  chemically  irregular.  It  may 
alternate  with  other  neuralgias  or  with  migraine,  or,  rarely,  it  is  associ- 
ated with  an  attack  of  the  latter.  It  is  occasionally  presented  by  hys- 
terics, particularly  if  their  attention  is  centered  on  the  stomach.  The 
gastralgic  attack  usually  comes  on  promptly  and  reaches  its  highest 
intensity  almost  at  once.  The  pain  is  an  agonizing,  boring,  cutting, 
burning  one,  and  may  be  localized,  diffuse,  or  in  a  girdle.  It  may 
radiate  along  the  loins  or  spine.  The  patients  relax  the  abdominal 
walls  and  make  deep  pressure  over  the  stomach  with  some  relief,  though 
there  may  be  much  superficial  sensitiveness.  Persistent  sensitive  spots 
are  often  found  over  the  lower  dorsal  vertebrae,  between  the  ribs,  and 
by  deep  prassure  over  the  abdominal  plexuses  of  the  sympathetic.  The 
face  is  pale,  distorted  witli  pain,  and  covered  with  sweat.  The  tempera- 
ture is  not  modified.  Tlie  attacks  may  be  of  only  a  few  minutes' 
duration  or  may  last  for  hours,  and  usually  terminate  rather  abruptly, 
often  with  the  vomiting  of  mucus  or  unchanged  food.  Food  is  then 
often  actively  craved  and  taken  without  distress. 

These  rather  rare  attacks  may  very  easily  be  mistaken  for  gall-stone 
colic,  acute  indigestion,  gastritis,  gastric  ulcer,  and  a  host  of  other  abdom- 


DISEASES   OF  THE  SPINAL   ACCESSORY  NERVE.  143 

inal  conditions  which  must  be  exchuled  to  make  tlie  diagnosis  possible. 
In  locomotor  ataxia  they  furnish  the  gastric  crisis  due  in  this  disease  to 
irritation  of  the  pneumogastric  nucleus  in  the  medulla,  where  any  other 
localized  lesion  may  provoke  them.  They  are,  as  a  rule,  associated  with 
constipation.  If  due  to  organic  nervous  disease,  the  treatment  and  prog- 
nosis correspond.  The  same  is  true  in  hysterical  cases.  Otherwise  the 
general  upbuilding  indicated  in  all  neuralgic  conditions  must  be  at- 
tempted. 

Rumination,  or  merycisra,  is  occasionally  observed  in  man.  The 
food  is  voluntarily  regurgitated,  remasticated,  and  again  swallowed. 
It  occurs  in  neurasthenics,  hysterics,  epileptics,  and  idiots.  Usually  the 
rumination  beoins  a  short  time  after  the  meal  and  lasts  for  half  an  hour. 
Such  patients  often  insist  that  they  are  unable  to-  control  the  habit, 
but,  except  in  idiots,  do  so,  at  least  to  some  extent,  in  the  presence  of 
strangers. 

Nervous  dyspepsia,  a  condition  set  up  by  Leube  as  a  gastric  neu- 
rosis, is  claimed  by  Ewald,  and  others  equally  competent,  to  be  but  a 
local  manifestation  of  neurasthenia.  Ewald  points  out  that  there  is  no 
peptic  deficiency,  and  even  Leube  based  his  diagnosis  largely  on  the  fact 
that  a  meal  is  thoroughly  digested  and  the  stomach  empty  within  the 
alleged  normal  limit  of  seven  hours.  The  digestive  difficulties  of  neu- 
rasthenia will  be  mentioned  under  that  caption. 


CHAPTER  X. 

DISEASES  OF  THE  SPINAL  PORTION  OF  THE  ACCESSORY 

NERVE. 

Anatomical  Considerations. — The  external  portion  or  spinal  part 
of  the  accessory  nerve  is,  properly  speaking,  not  a  cranial  nerve  at  all. 
Arising  by  a  series  of  roots  from  multipolar  cells  in  the  anterior  spinal 
gray  matter  throughout  the  cervical  cord  as  low  as  the  sixth  segment,  it  is 
finally  gathered  into  a  bundle  or  trunk.  This  passes  upward  through  the 
foramen  magnum  and  joins  the  true  accessory  portion.  It  then  passes 
with  it  through  the  jugular  foramen,  when  it  finally  separates  to  be  dis- 
tributed to  the  sternomastoid,  which  it  entirely,  and  to  the  trapezius  mus- 
cle, which  it  partly,  furnishes  with  motor  and  tro]ihic  control.  The  trape- 
zius is  also  supplied  by  numerous  spinal  branches,  particularly  in  its  lower 
portion,  and  only  depends  on  the  spinal  accessory  in  its  upper  half,  though 
Bailey  ^  reports  a  case  in  wdiich  division  of  the  spinal  accessory  paralyzed 
the  trapezius  and  sternomastoid  completely  and  produced  a  serious  disa- 
bility. Tliis  nerve  may  be  centrally  or  peripherally  affected,  and  the 
result  is  spasmodic  or  paralytic  as  the  lesion  is  irritative  or  destructive. 

Accessory  Spasm. — Spasmodic  Torticollis,  Spasmodic  Wryneck. — Ir- 
ritative lesions  of  the  spinal  accessory  produce  characteristic  action  and 

1  "  Ann.  of  Svirg. ,''  May,  1901. 


144  DISEASES  OF   THE   CRANIAL  NERVES. 

prominence  in  the  muscles  it  supplies.  By  the  sternomastoid  the  face  is 
carried  forward,  turned  toward  the  opposite  side,  and  tilted  upward.  The 
trapezius  draws  the  head  backward  and  to  the  same  side,  lifts  the  shoul- 
der, and  shortens  the  distance  between  the  occiput  and  acromion.  At 
the  same  time  the  scapula  is  drawn  nearer  the  vertebral  spines  as  well  as 
upward.  Both  sternals  acting  together  bring  the  head  forward  and 
downward.  Both  trapezii  carry  the  head  backward  and  the  face  up- 
ward. Acting  alternately  they  turn  the  head  from  side  to  side  with 
slight  rotation.  The  spasm  may  be  clonic  or  tonic,  may  involve  one 
or  both  sides,  and  may  be  limited  to  the  sternals  or  the  trapezii.  A  tend- 
ency to  spread  to  other  muscles  of  allied  function  is  often  observed.  As 
a  matter  of  fact,  in  most  cases  of  wryneck  more  muscles  are  involved 
than  those  supplied  by  the  accessory  nerves.  Thus  the  splenius  and  the 
small  rotators  are  frequently  associated  in  the  spasm,  just  as  they  are 
related  functionally.  The  large  muscles  named  are,  however,  the  ones 
most  at  fault  and  the  ones  that  impress  a  given  case  with  its  distinctive 
movement  or  attitude.  The  trapezius  is  less  often  clonically  involved 
than  the  sternomastoid,  but  is  as  frequently  aflPected  by  tonic  spasms. 
In  some  cases  clonic  torticollis  is  a  localized  tic,  or  it  may  be  a  portion 
of  a  more  widely  distributed  tic  such  as  that  arising  in  the  face  and 
gradually  involving  the  neck,  shoulder,  and  arm.  In  a  mild  form  it 
furnishes  the  habit  spasm  that  follows  chorea  sometimes  or  is  picked  up 
by  pubescent  youths.  We  may  also  have  a  mental  torticollis  as  de- 
scribed by  Bompaire,^  in  which  the  patient  can  not  voluntarily  restore  the 
head  to  its  natural  position,  but  turns  it  readily  in  all  directions  if  allowed 
to  press  it  against  any  object,  or  to  apply  an  insignificant  amount  of  man- 
ual assistance.  The  spasm  is  here  the  result  of  a  mental  obsession.  The 
nodding  spasm  of  hysteria  arises  in  the  same  way,  and  in  both  the 
disorder  must  be  referred  to  the  cortex.  In  this  connection  the  subject 
of  tics  in  Part  VII  should  be  read.  Cerebral  tumors,  meningitis,  focal 
softenings,  and  disease  of  the  medulla  may  underlie  the  spasm.  Cervical 
spondylitis  and  meningitis  usually  produce  tonic  spasms.  The  action 
of  cold,  cervical  adenitis,  and  violent  wrenching  of  the  neck  may  peri- 
pherally excite  them.  Torticollis  has  been  reflexly  produced  by  intes- 
tinal worms. 

Treatment  is  often  highly  unsatisfactory.  The  variety  due  to  cold 
usually  subsides  spontaneously  or  may  be  benefited  by  local  applications 
and  antirheumatics.  The  hysterical  form  may  suddenly  cease.  The  cases 
dependent  upon  organic  lesions  are  often  beyond  reach.  Sedatives  like 
cannabis  indica,  opium,  and  hyoscin  only  give  temporary  relief  and  often 
upset  the  stomach  or,  unfortunately,  lead  to  their  habitual  use.  When 
the  spasm  is  severe,  and  especially  if  confined  to  one  side,  wide  resection 
of  the  spinal  accessory  nerve  before  its  entrance  into  the  sternomastoid 
is  advised,  other  means  having  failed.  A  tic  or  habit  is  thus  likely  to  be 
benefited  for  a  time,  but  is  also  likely  to  reappear  in  some  adjoining  area. 
Stretching  the  nerve  is  almost  sure  to  be  followed  by  a  relapse  of  the  tic 
as  the  nerve  I'ecovers,  as  is  the  case  also  if  the  divided  nerve  unites. 

1  "Thfesede  Paris." 


DISEASES   OF   THE  SPINAL   ACCESSORY  NERVE. 


145 


The  upper  spinal  nerves  to  the  small  rotators  must  in  some  cases  also 
be  divided  to  completely  quiet  the  spasm. 

Children   sometimes   present  a  permanent  wryneck  of  an  entirely 
different  character.      Owinff  to  traction  on  the  head  and  twisting  of  the 


Fig.  61. — Difficulty  in  raising  arm  after  division  of  left  spinal  accessory. 


^^ 


J 


neck  in  labor,  or  even  in  unaided  labor,  the  sternomastoid  may  be  in- 
jured, and  subsequent  contracture  shortens  it.  The  result  is  a  iirm, 
^brous  band  that  holds  the  face  to  the  opposite  side.  Inflammatory 
injury  to  the  muscle  in  adults  may  cause  the  same  thing:,  and  in  both 
-cases  it  can  be  remedied  only  by  thorough 
division  of  the  shortened  tissues. 

Accessory  Paralysis. — Cortical  disease 
very  exceptionally  results  in  complete  and 
permanent  loss  of  power  in  the  spinal  ac- 
<5essory  area.  Like  those  of  other  bilateral 
movements,  these  muscles  seem  fully  repre- 
sented in  both  hemispheres.  As  a  part  of 
nuclear  disease,  as  in  progressive  muscular 
atrophy,  the  spinal  centers  are  often  involved, 
with  a  corresponding  loss  of  power  and  nu- 
trition. By  meningitis  the  trunks  of  one  or 
both  nerves  may  be  implicated  at  the  fora- 
men magnum.  The  hypoglossal  is  then 
likely  to  suifer  with  them,  and  the  true  ac- 
cessory fibers  are  usually  also  aifected.  Out- 
side the  skull  the  spinal  portion  of  the  ac- 
cessory is  sometimes  involved  in  wounds, 
operations,    deep-seated    tumors,     vertebral 

caries,  cervical  adenopathy,  and  by  neuritis.  The  unilateral  symptoms 
are  loss  of  power  and  wasting  in  the  related  muscles.  This  involves 
the  sternomastoid  almost  entirely  and  the  trapezius  only  in  its  upper 
portion.  The  head  is  not  so  readily  and  strongly  turned  to  the  opposite 
10 


I 


Fig.  62.  —  Drooping  sboulder, 
lengthening  of  neck,  and  rotation 
of  r-capula  after  division  of  left  spinal 
accessory. 


146  DISEASES  OF  THE  CRANIAL  NERVES. 

side,  the  shoulder  droops  slightly,  and  the  extension  power  of  the  arm 
is  lessened.  The  scapula  moves  outward,  especially  its  upper  inner 
angle,  and  stands  out  from  the  ribs.  The  curved  line  from  mastoid  to 
acromion  becomes  depressed  and  even  angular  upon  efforts  at  deep  in- 
spiration or  in  extending  both  arms  against  resistance.  Subsequent 
contracture  in  the  unopposed  muscles  of  the  sound  side  may  turn  the 
face  to  the  primarily  affected  side. 

In  the  bilateral  form,  usually  due  to  meningitis  or  vertebral  caries, 
the  head  is  held  insecurely  and  readily  falls  forward  or  backward  as  the 
trapezius  or  sternals  are  most  affected.  Injury  to  the  spinal  accessory 
in  the  posterior  triangles  of  the  neck  after  it  has  passed  through  the 
sternomastoid  only  affects  the  trapezius.  The  treatment  is  that  of  the 
causal  condition  in  the  given  case.  In  neuritis  electrical  stimulation  is 
indicated,  and  nerve-suture  would  be  required  in  the  cases  where  the 
nerve  had  been  divided. 


CHAPTER   XL 
DISEASES  OF  THE  HYPOGLOSSAL  NERVE. 

Anatomical  Considerations. — The  twelfth  cranial  nerve  is  a 
purely  motor  nerve  for  the  muscles  of  the  tongue  and  subserves  their 
nutrition.  Its  cortical  centers  adjoin  those  for  the  lips  in  the  lower 
portion  of  the  ascending  frontal  gyre.  Its  lower  neuron  arises  in  the 
hypoglossal  nucleus  under  the  floor  of  the  fourth  ventricle.  This  nu- 
cleus is  close  to  the  median  line,  and  is  made  up  of  large  cells  analogous 
to  those  in  the  anterior  spinal  horn  of  gray  matter.  The  nerve-trunk 
arises  by  a  number  of  roots  in  the  groove  outside  of  the  olivary  body, 
and,  passing  forward,  leaves  the  skull  by  the  anterior  condyloid  fora- 
men of  the  occipital  bone.  It  has  a  connection  with  the  pneumogastric, 
which  it  accompanies  a  short  distance,  and  receives  a  branch  from  the 
upper  spinal  nerves.  This  branch  eventually  innervates  the  depressors 
of  the  hyoid  bone,  and  is  not  affected  by  injury  to  the  hypoglossal 
nucleus.  The  hypoglossas  may  be  injured  or  diseased  in  any  part  of  its 
course  from  the  cortex  to  the  peripheral  branches,  and  manifests  such 
injury  by  spasm,  paresis,  and  paralysis,  as  the  causal  state  is  irritant, 
inhibitive,  or  destructive.  In  addition,  injury  at  or  below  the  nucleus 
entails  atrophy  of  the  muscular  fibers  of  the  tongue.  The  mucous  por- 
tion of  the  tongue  is  supplied  by  the  trifacial. 

Hypoglossal  Spasm. — The  tongue  is  usually  involved  in  epileptic 
convulsions,  and  is  frequently  bitten  in  consequence  of  having  been 
thrust  between  .the  teeth  by  the  action  of  the  genioglossus  muscles  and 
lacerated  by  the  spasmodic  action  of  the  masticators.  This  may  occur 
in  very  slight  attacks,  when  no  convulsive  action  in  the  extremities  is 
observed.  At  an  early  stage  of  hysterical  convulsions  the  tongue  is 
usually  protruded  violently,  but  is  only  bitten  in  extremely  rare  cases. 
This  lingual  spasm  may  comprise  the  entire  motor  disturbance  in  some 
hysterical  cases.  In  chorea  the  tongue  is  usually  involved  in  the  mus- 
cular twitchings  that  mark  the  disease,  and  is  often  the  seat  of  vigorous 


DISEASES  OF   THE  HYPOGLOSSAL   NERVE.  147 

choreic  movement,  in  which  it  may  be  protruded  and  even  slightly 
bitten.  The  speech  difficulties  of  this  disease  are  due  in  part  to  the 
lingual  spasm.  From  forced  overuse,  as  in  public  speakers,  it  is  some- 
times the  seat  of  a  neurotic  manifestation  similar  to  writers'  cramp,  a 
condition  termed  aphthongia.  Slight  spasm  also  occurs  in  stammering 
and  in  stuttering.  I^ingual  spasm  has  been  reflexly  dependent  upon  de- 
cayed teeth  and  cured  by  their  removal. 

Cortical  irritation  has,  in  rare  instances,  given  rise  to  lingual  spasms 
that  practically  constitute  Jacksonian  epileptic  attacks.  The  lips  and 
face  usually  participate  in  the  spasm,  as  the  contiguity  of  their  centers 
would  lead  one  to  expect.  In  some  of  these  cases  the  initial  convulsion 
has  been  a  generalized  fit ;  in  others  such  attacks  have  followed.  It  is 
conceivable  that  nuclear  irritation  might  give  rise  to  similar  manifesta- 
tions, but  post-mortem  data  for  this  belief  are  lacking.  The  treatment 
would  be  that  of  the  general  condition  underlying  the  local  manifestation. 

Hypoglossal  Paralysis. — The  hypoglossus  nerve  may  be  paralyzed 
by  injury  at  any  point  in  its  course.  In  rare  cases  a  limited  cortical 
lesion  has  produced  paralysis  of  the  opposite  side  of  the  tongue.  More 
wide-spread  cortical  lesions  and  lesions  in  the  supranuclear  motor  tract 
usually  produce  a  one-sided  paresis  or  paralysis  of  the  tongue,  which,  on 
protrusion,  deviates  toward  the  paralyzed  side, — that  is,  away  from  the 
lesion.  This  is  due  to  the  action  of  the  unaffected  and  properly  acting 
genioglossus  of  the  sound  side.  Nuclear  disease  usually  produces  bi- 
lateral palsy  of  the  tongue,  which  lies  motionless  in  the  floor  of  the  mouth, 
and,  after  a  few  days,  rapidly  wastes.  A  few  cases  of  one-sided  nuclear 
disease  are  recorded.  In  bulbar  palsy,  syringomyelia,  and  tabes  it  is 
thus  affected  in  exceptional  cases.  Other  cranial-nerve  nuclei  usually 
suffer  at  the  same  time,  and  the  resulting  symptoms  enable  one  to 
localize  the  disease.  The  fibrillar  twitchings  in  the  tremulous  tongue 
of  paretic  dementia  and  some  of  the  stammering  of  this  malady  are  due 
to  the  nuclear  and  cortical  invasion  of  the  disease.  The  root  of  the 
nerve  in  its  passage  through  the  medulla  is  sometimes  damaged  by  a  local 
lesion,  which  of  necessity  interferes  with  the  pyramidal  tracts  for  the 
opposite  side  of  the  body  and  produces  a  crossed  paralysis  of  the  tongue 
and  limbs.  The  tongue,  in  such  an  instance,  would  deviate  from  the 
paralyzed  side  of  the  body  and  toward  the  side  of  the  lesion.  Such  a 
crossed  palsy,  due  to  disease  of  the  olivary  body,  has  been  reported.  ^ 
Basilar  processes,  like  meningitis  and  fractures,  or  bone  disease  involv- 
ing the  condyloid  foramen,  may  injure  the  nerve  in  its  intracranial 
course.  Outside  of  the  skull  it  is  vulnerable  to  penetrating  wounds,  or 
may  be  implicated  in  deep  abscesses,  as  from  caries  of  the  upper  verte- 
brae. Here  its  neighbors,  the  spinal  accessory  and  the  pneumogastric, 
are  likely  to  be  involved  at  the  same  time. 

In  unilateral  hypoglossal  paralysis  due  to  damage  of  the  nerve  at  or 
below  the  nucleus,  the  paralyzed  side  of  the  tongue  shows  a  marked 
loss  of  volume.  This  does  not  follow  supranuclear  lesions.  The  mucous 
covering,  on  the  other  hand,  not  being  deprived  of  its  trophic  supply,  is 
thrown  into  marked  and  apparently  excessive  folds.  Taste  and  sensation 
1  Goukovsky,  "Nouvelle  Iconographie  de  la  Salpetriere^ "  No.  3,  1895. 


148  DISEASES  OF  THE   CRANIAL  NERVES. 

are  not  impaired.  Mastication  on  the  paralyzed  side  of  tlie  tongue  is  not 
well  performed,  as  the  patient  finds  difficulty  in  placing  and  maintaining 
the  food  between  the  teeth.  When  protruded,  the  tongue  curves  sharply 
to  the  wasted  side,  but  within  the  mouth  motions  toward  the  palsied  side 
are  wanting.  In  the  bilateral  form  speech  is  much  aifected,  as  nearly 
all  consonant  sounds  depend  in  some  degree  upon  the  position  of  the 
tongue.  Swallowing  is  also  difficult,  as  the  bolus  or  fluid  is  not  readily 
carried  backward  into  the  pharynx  and  mastication  is  greatly  impeded. 
Treatment  is  directed  to  the  causal  condition,  aside  from  which  it 
is  practically  hopeless. 


CHAPTER  XII. 

MULTIPLE  PARALYSES  OF  C3^ANIAL  NERVES, 

In  discussing  the  cranial  nerves  separately,  frequent  reference  has 
been  made  to  their  association  in  diseased  processes.  Sometimes  the 
limitation  of  this  association  is  of  diagnostic  importance,  as  when  the 
loss  of  hearing  with  facial  palsy  locates  a  lesion  of  the  seventh  and 
eighth  nerves  in  their  parallel  intracranial  course  or  within  the  internal 
meatus  auditorius.  In  meningitis  and  other  basilar  processes  a  number 
of  cranial  nerves  are  usually  implicated  at  once,  and  such  multiple 
paralyses  of  cranial  nerves  become  symptomatically  highly  important. 
The  close  juxtaposition  of  the  cranial  nuclei  has  been  repeatedly  pointed 
out  as  giving  rise  to  associated  palsies  in  bulbar  disease,  such  as  tumor, 
hemorrhage,  and  limited  basilar  thrombosis.  In  their  cortical  fields 
and  their  supranuclear  motor  paths  a  number  of  the  cranial  nerves  may 
also  be  injured  at  once  by  traumatism  or  disease.  Hypoglossal  palsy 
with  hemiplegia  has  just  been  called  to  attention,  as  well  as  the 
association  of  hypoglossal  and  facial  spasm  due  to  the  cortical  relations 
of  their  centers.  These  multiple  cranial  palsies  are  principally  of  symp- 
tomatic interest  and  value,  but  there  are  groups  of  nuclear  palsies  of 
the  cranial  nerves  that  present  well-marked  clinical  forms  of  disease. 
Their  pathological  anatomy  is  largely  confined  to  the  upward  extension 
of  the  spinal  gray  that  furnishes  the  chain  of  cranial-nerve  nuclei 
reaching  from  the  lower  angle  of  the  floor  of  the  fourth  ventricle  to  the 
posterior  portion  of  the  third.  Anatomically  and  clinically  these  dis- 
eases fall  into  two  forms  :  First,  those  of  the  upper  group,  primarily 
implicating  the  nuclei  of  the  third,  fourth,  and  sixth  nerves  (see 
Fig.  36),  and,  second,  those  first  implicating  the  remaining  lower  cranial 
nuclei.  As  these  diseases  are  sometimes  inflammatory  in  character  and 
analogous  to  poliomyelitis,  they  have  come  to  be  known  respectively  as 
polio-encephalitis  superior  and  polio-encephalitis  inferior.  More  com- 
monly the  process  is  one  of  degeneration.  The  analogy,  or  in  some 
cases  the  identity,  of  the  disease  of  tlie  nuclei  of  the  bulb  with  that  of 
the  anterior  gray  of  the  cord  is  now  generally  conceded.  It  is  the  same 
process  arising  in  different  localities,  but  affecting  homologous  elements 


MULTIPLE  PARALYSES   OF  CRANIAL  NERVES.  149 

and  producing  results  similar  in  kind.  Transition  and  combination 
cases  of  eveiy  variety  are  of  record.  Commencing  in  the  upper  nuclei 
of  the  ocular  nerves,  the  lower  bulbar  levels  may  be  progressively  in- 
vaded, and  later  spinal  features  may  be  added  ;  or,  beginning  in  the 
bulbar  nuclei,  an  upper  extension  may  induce  progressive  ophthal- 
moplegia. In  the  same  way  that  the  spinal  type  of  the  disease  may 
be  acute,  subacute,  and  chronic,  we  have  an  acute,  subacute,  and  chronic 
polio-encephalitis  superior  and  inferior,  and  forms  combining  both. 

Polio-encephalitis  superior  chronica  will  be  considered  first,  as  it 
presents  the  most  complete  and  well-defined  picture.  It  is  also  called 
progressive  oplithahnoplegia  and  chronic  nuclear  ocular  paralysis.  It  is 
characterized  by  the  gradual  loss  of  power  in  the  external  and  internal 
muscular  apparatus  of  the  eyeball,"  one  set  of  muscles  after  another 
being  gradually  involved.  Usually  bilateral,  it  may  be  confined  to  one 
eye  for  a  period  even  of  years  and  then  invade  the  other.  As  a  rule 
progressive,  it  may  come  to  a  permanent  standstill  at  any  time,  or  ad- 
vance intermittently. 

Etiology. — Polio-encephalitis  superior  has  in  so  many  cases  followed 
infectious  and  toxic  states  that  it  has  with  reason  been  attributed  in  some 
cases  to  pneumonia,  grip,  diphtheria,  and  syphilis ;  to  lead,  sulphid 
of  carbon,  carbonic-oxid  gas,  sulphuric  acid,  and  alcohol.  These  toxic 
agents,  however,  are  more  common  in  the  causation  of  the  acute  variety, 
which  may  terminate  by  becoming  chronic.  It  may  be  secondary  to  or 
a  part  of  tabes  dorsalis,  and  the  characteristic  Argyll-Robertson  pupil 
of  that  disease  is  a  part  of  it.  It  is  similarly  related  to  posterolateral 
spinal  sclerosis,  general  paresis,  and  insular  sclerosis.  It  may  be  an  up- 
ward extension  of  identical  disease  in  the  cord  or  bulb.  It  is  more 
frequent  in  men  than  in  women,  and  while  it  may  appear  at  any  age,  it 
is  principally  a  disease  of  adult  life.  In  some  cases  there  seems  to  be 
a  teratological  defect,  congenitally  manifest  or  appearing  during  the 
active  periods  of  growth. 

Pathological  Anatomy. — The  lesions  are  variable  in  extent.  They 
involve  the  upper  cranial-nerve  nuclei  on  one  or  both  sides,  including 
those  of  the  third,  fourth,  and  sixth  nerves,  wholly  or  in  part.  When 
partial,  the  iridociliary  nucleus  of  the  third  and  its  adjoining  nucleus  for 
the  elevator  of  the  lid  most  frequently  escape  or  are  only  partly  des- 
troyed. The  corresponding  nerve-trunks  and  muscles  are  degenerated 
and  atrophied.  In  addition  are  encountered  cerebral,  bulbar,  and  spinal 
conditions,  of  which  polio-encephalitis  superior  sometimes  is  but  a  part. 
Microscopically,  especially  in  the  early  stage,  some  hyperemia  is  found 
about  the  nuclei.  Later  the  cells  of  these  nuclei  lose  their  prolonga- 
tions, are  diminished  in  size,  present  vacuoles  and  pigmentary  degenera- 
tion. Some  completely  disappear,  and  in  eases  of  long  standing  but  a 
few  atrophied  remnants  remain.  Slight  capillary  hemorrhages  or  their 
traces  can  at  times  be  determined.  Some  leukocytal  infilti'ation  occurs 
about  the  vessels  or  in  the  foci  of  the  disease,  and  minute  sclerotic  patches 
are  found.     Rarely  the  lining  of  the  Sylvian  aqueduct  is  thickened. 

Symptoms. — In  the  fully-developed  cases  the  facies,  classically  de- 
scribed by  Hutchinson,  and  recognized  by  Brunner,  von  Graefe,  Char- 


150  DISEASES   OF  THE   CRANIAL  NERVES. 

cot,  and  others,  is  most  striking.  The  drooping  lids  partly  covering  the 
eyes  cause  the  patient  to  hold  the  head  back  and  strain  with  the  frontalis 
to  overcome  the  partial  ptosis.  The  brow  is  thrown  into  deep  trans- 
verse wrinkles.  The  immobile  eyes  and  inactive  pupils  are  like  those 
of  glass  in  a  mask  of  wax.  They  usually  deviate  outward,  as  the  sixth 
nucleus  is  often  spared  at  first ;  but  any  squint  may  in  various  cases 
be  present  or  the  visual  axes  may  conform.  The  ptosis  is  usually  less 
marked  after  a  night's  rest ;  and  if  the  ocular  muscles  still  retain  a  slight 
degree  of  activity,  this,  too,  is  best  in  the  morning.  Diplopia  is  rarely 
mentioned  by  these  patients,  which  Blanc  attributes  to  the  slowness  with 
which  the  deviation  develops,  thereby  allowing  the  brain  to  neglect  one 
image.  In  partial  cases  the  ocular  conditions  may  be  unilateral  or  they 
may  be  only  functionally  distributed  and  bilateral  or  unilateral.  Thus 
the  iris  may  react  for  light  or  accommodation,  or  both.  The  abducens 
may  at  first  escape  or  first  be  involved,  and  innumerable  combinations 
and  varieties  have  been  encountered  as  one  or  many  nuclei  were  par- 
tially or  completely  affected. 


Fig.  63.— Polio-encephalitis  superior  and  inferior.  1,  Myopathic  facies ;  mask-like,  expressionless 
face,  drooping  eyelids,  etc. ;  2,  forced  attempt  to  smile  vigorously  ;  3,  forced  attempt  to  close  eyes  firmly 
and  to  protrude  tongue  vigorously:  it  passed  the  lips  with  difficulty ;  the  eyeballs  were  hardly  covered. 

The  general  health  of  the  patient  may  leave  little  to  desire  or  he  may 
present  the  somatic  conditions  and  functional  disturbances  that  belong 
to  the  associated  diseases  already  mentioned.  In  some  instances  involve- 
ment of  the  fifth  nerve,  probably  through  its  descending  root,  has  given 
rise  to  paresthesia  or  anesthesia  in  the  face. 

Course. — The  evolution  of  the  disease  is  one  of  its  most  distinctive 
features.  Commencing  with  a  ptosis  or  a  squint,  the  other  features  of 
the  disease  are  gradually  added  during,  perhaps,  several  years.  Sta- 
tionary periods  of  long  duration — twenty -five  years  in  a  case  of  Striim- 
pell's — may  intervene,  and  finally  the  disease  takes  up  its  progressive 
course,  perhaps  without  appreciable  cause.  Extensions  of  the  process 
to  the  bulbar  region  may  occur,  and  we  have  bulbar  palsy  or  polio- 
encephalitis inferior  added  and  the  prognosis  for  life  becomes  much 
darkened.  The  lesions  may  not  stop  at  the  bulb,  but  may  invade  the 
cord,  producing  a  progressive  spinal  muscular  atrophy  of  any  one  of  the 
various  types  of  that  disease. 


3IULTIPLE  PARALYSES  OF  CRANIAL  NERVES.  151 

The  diagnosis  depends  largely  upon  the  evolution  of  the  disease 
and  its  progressive  course.  AVhen  thoroughly  developed  its  remarkable 
facies  is  not  easily  mistaken.  The  acute  form,  and  hemorrhage,  inflam- 
mation, and  softening,  give  a  history  of  rapid  onset  and  promptly  reach 
their  maximum  stage.  In  multiple  neuritis,  especially  the  alcoholic 
and  diphtheric  varieties,  confusion  is  likely  to  arise,  but  we  may  gener- 
ally be  guided  by  the  condition  of  the  extremities  and  the  wide  diffusion 
of  the  disease.  Even  then  we  can  not  absolutely  exclude  the  cranial 
nuclei,  which  may  become  the  seat  of  a  chronic  atrophic  process.  An 
orbital  tumor  may  give  rise  to  a  partial  and  increasing  ophthalmoplegia, 
but  pressure  symptoms,  exophthalmos,  and  optic  atrophy  will  finally 
distinguish  it.  Basilar  processes  and  bulbar  growths,  aside  from  the 
distinctive  symptoms  to  which  they  give  rise,  usually  implicate  so  many 
nerves  and  the  pyramidal  tracts  that  they  can  be  easily  separated. 

Treatment  turns  practically  upon  the  presence  or  suspicion  of 
syphilis,  which  should  be  vigorously  managed.  Other  toxic  possibili- 
ties, such  as  lead-poisoning,  will  require  appropriate  intervention. 
Strychnin  does  temporary  good  sometimes.  Electricity  is  futile,  as  it 
can  not  be  applied  to  the  faulty  muscles.  In  the  majority  of  cases  the 
physician  is  helpless. 

Acute  and  Subacute  Polio-encephalitis  Superior. — The  acute 
form  is  very  rare.  Like  its  congener,  acute  poliomyelitis,  it  may  be 
purely  an  infectious  disease,  and  has  been  noted  in  epidemics  of  the 
spinal  disease.  It  may  follow  many  acute  infections,  as  mentioned  in 
the  etiology  of  the  chronic  form,  especially  diphtheria,  pneumonia,  and 
influenza.  The  subacute  form,  while  in  some  cases  attributable  to  the 
above  causes,  is  more  often  due  to  syphilis  and  toxic  agents,  like  lead 
and  the  carbon  gases.  The  onset  is  sudden  or  very  acute,  and  the 
disease  may  reach  a  fatal  termination  in  a  few  days  or  a  week,  usually 
from  implication  of  the  bulbar  centers.  The  nuclei  in  several  such 
cases  have  presented  no  post-mortem  changes  that  could  be  discovered. 
Brissaud  ^  supposes  that  the  infection  has  overwhelmed  the  nuclei  be- 
fore histological  traces  discoverable  by  our  present  means  of  investi- 
gation were  developed.  The  similarity  to  Landry's  paralysis  in  this 
regard  is  striking,  and  the  diseases  may  be  essentially  the  same,  varying 
only  in  localization.  In  other  cases  well-marked  inflammatory  changes 
have  been  discerned.  The  prognosis  is  very  grave,  especially  in  chil- 
dren. Some  cases  come  to  a  standstill ;  others  develop  into  the  chronic 
variety. 

The  treatment  should  be  directed  to  securing  perfect  rest  and  the 
removal  of  any  source  of  infection  or  intoxication  and  its  eradication 
from  the  system  before  important  changes  occur. 

Polio-encephalitis  inferior  chronica  is  the  term  employed  by 
Wernicke  to  denominate  the  disease  first  described  by  Dumesnil,  later  by 
Duchenne,  as  progressive  paralysis  of  the  tongue,  palate,  and  lips.  It  is 
also  known  as  labioglossolaryngeal  or  pharyngeal  paralysis  (Leyden), 
as  progressive  bulbar  pay^alysis  (Wachsmuth),  as  paralysis  of  the  bulbar 

1  '-Lecous,"  1895. 


152  DISEASES  OF  THE   CRANIAL  NERVES 

nuclei  (Kussmaul),  and  as  progressive  bulbar  palsy.  It  consists  in  a 
progressive  paralysis  of  the  lips,  tongue,  phaiynx,  and  larynx,  with 
wasting  of  their  muscles,  and  usually  terminates  in  death  from  pneu- 
mogastric  palsy.  The  disease  process  is  limited  to  the  nuclei  and  lower 
neurons  of  the  seventh,  ninth,  tenth,  eleventh,  twelfth,  and  the  motor 
portion  of  the  fifth  cranial  pairs.  It  is  identically  the  same  in  charac- 
ter with  progressive  spinal  muscular  atrophy,  with  which  it  is  often 
associated. 

Etiology. — Males  and  females  are  about  equally  susceptible  to  this 
disease.  Though  it  has  rarely  been  observed  in  childhood  and  may  be  a 
congenital  or  teratological  deficiency,  it  usually  appears  after  the  age  of 
thirty.  Occasionally,  and  then  ordinarily  as  a  part  of  a  more  extensive 
spinal  atrophy,  or  in  association  with  superior  polio-encephalitis,  it  has 
appeared  in  successive  generations  or  in  more  than  one  member  of  the 
same  family.  These  family  cases  usually  develop  in  early  life.  It  has 
been  attributed  to  exposure  to  cold  ;  to  the  overuse  of  the  mouth-muscles, 
as  in  players  of  wind-instruments  and  glass-blowers  ;  to  syphilis,  to 
Bright's  disease,  and  other  wasting  maladies.  It  may  be  a  part  of 
amyotrophic  lateral  sclerosis.  It  has  appeared  in  tabes  dorsalis,  in- 
sular sclerosis,  syringomyelia,  and  followed  descending  degeneration  of 
the  pyramidal  tracts  after  cerebral  lesions.  Knowledge  of  the  role  of 
toxemia  in  these  chronic  disturbances  is  widening.  Progressive  bul- 
bar palsy  has  been  known  to  follow  lead  intoxication  and  diphtheric 
poisoning.  Often  the  causation  is  entirely  obscure,  but  advances  in  the 
field  of  auto-intoxication  may  throw  light  on  this  darkness. 

Morbid  Anatomy. — The  lesion  is  limited  to  the  nuclear  cells  in  the 
lower  half  of  the  bulb.  It  is  practically  symmetrical.  The  hypo- 
glossal nucleus  is  most  severely  affected,  as  a  rule.  The  nuclei  of  the 
true  spinal  accessory,  the  facial,  the  motor  portion  of  the  trifacial,  and 
the  pneumogastric  are  invaded  with  decreasing  intensity  and  frequency. 
A  degenerative  process  is  found  in  the  nerve-trunks  whose  nuclei  are 
affected  and  their  muscular  terminations  waste.  The  muscle-fibers 
themselves  show  corresponding  degeneration  and  atrophic  conditions. 
The  minute  anatomy  is  the  same  as  that  in  progressive  ophthalmoplegia 
or  that  of  progressive  spinal  muscular  atrophy,  to  which  the  reader, 
bearing  in  mind  the  special  location  of  this  disease,  is  referred.  The 
organic  changes  of  associated  atrophies  and  scleroses  or  of  primar}^  con- 
ditions, such  as  tabes,  syringomyelia,  insular  sclerosis,  and  descending 
cerebral  degenerations  are  at  times  encountered. 

Symptoms. — The  symptoms  begin  insidiously  and  progress  slowly. 
The  tongue  is  usually  the  first  affected.  This  is  manifest  in  a  thick- 
ened pronunciation,  particularly  of  the  letters  which  require  definite 
lingual  movements.  The  linguodentals  and  linguopalatals  (see  table, 
p.  66)  and  the  vowel  "  e  "  and  later  on  the  explosive  labial  sounds  are 
lost.  Finally  speech  is  reduced  to  unmodified  laryngeal  noises  that  are 
quite  unintelligible.  When  the  disease  is  only  slightly  developed,  by  an 
effort  tire  patient  can  often  enunciate  clearly  and  the  embarrassment  may 
be  noticed  only  in  ordinary  inattentive  conversation.  The  tongue  also 
progressively  loses  its  muscular  strength  and  range  of  motion  until  it 


3IULTIPLE  PARALYSES  OF  CRANIAL   NERVES. 


153 


lies  a  flabby,  inert,  rugose,  atrophic  mass  on  the  floor  of  the  mouth.  It 
loses  its  function  of  maintaining  the  food  between  the  teeth  during  mas- 
tication and  of  carrying  the  bolus  backward  and  thrusting  it  into  the 
pharynx   in   efliirts   at  swallowing.      It   can  no   longer   be   protruded, 


Fig.  04.— Case  of  bulbar  palsy.    1,  Photograph  taken  shortly  before  first  symptoms  were  noted  ;  2,  photo- 
graph taken  four  years  later,  a  few  weeks  before  death. 


turned  to  either  side,  rolled  up,  or  hollowed  into  a  gutter.  In  most  of 
the  cases  it  notably  wastes,  but  as  the  atrophy  is  confined  to  the  mus- 
cular portion  of  the  tongue,  the  dermal  covering  appears  too  large  and 
may  even  suggest  epidermal  hypertrophy. 

The  lips  are  affected  shortly  after  the  tongue,  and  this  adds  to  the  speech 
difficulty  by  rendering  the  pro- 
nunciation of  the  vowels  "o"  and 
"  u "  uncertain  or  impossible. 
The  labial  consonants  are  lost  as 
above  indicated,  and  little  be- 
sides the  sibilant  "  s "  and  the 
open  vowel  "  a  "  remain.  The  or- 
bicularis oris  is  usually  the  first 
labial  muscle  invaded,  but  all 
of  the  labial  group  are  even- 
tually paralyzed.  Their  nuclear 
association  with  the  hypoglossus 
and  their  functional  relationship 
will  be  recalled.  At  first  whist- 
ling and  blowing  efforts  are 
weakened,  but  finally  the  mouth 
hangs  loosely,  the  lower  lip 
drooping  away  from  the  teeth, 
and    all    voluntary    movements 

are  lost.  This,  with  the  action  and  eventual  contracture  of  the  zygoma- 
tics, serves  to  greatly  accentuate  the  nasolabial  furrows  and  imparts  a 
demented  appearance  to  the  lower  portion  of  the  face. 

Out  of  the  drooping,  open  mouth  saliva  drules,  requiring  the  constant 


Fig.  65. — Mouth  in  bulbar  palsy.  Voluntary  maxi- 
mum opening  and  attempt  to  project  the  tongue.which 
lies  inert  and  shrunken  in  the  floor  of  the  mouth. 


154  DISEASES  OF  THE   CRANIAL   NERVES. 

use  of  a  napkin  or  handkerchief.  The  quantity  is  sometimes  enormous 
and  always  appears  greater  than  normal.  When  the  masseters  and 
jjtery golds  are  involved,  which  is  usually  at  a  late  stage,  but  may  be  an 
initial  condition,  mastication  is  feeble  or  impossible.  Finally,  their 
complete  paralysis  allows  the  mandible  to  hang  loosely,  increases  the 
opening  of  the  drooping  mouth  and  the  salivary  overflow.  The  jaw- 
jerk  is  abolished  except  in  those  cases  where  spastic  symptoms  elsewhere 
point  to  the  association  of  the  pyramidal  tracts  in  the  lesion.  It  is 
then  increased.  The  lips  usually  show  marked  atrophy  and  are  sensibly 
thinned.  This  is  sometimes  obscured  by  the  fatty  deposit,  but  in  the 
final  stages  is  practically  a  constant  condition. 

The  palate  follows  the  lips  in  order  of  involvement  in  a  majority  of 
cases.  Its  loss  of  mnscular  tone  is  manifested  by  the  nasal  voice  tones, 
which  also  adds  to  the  lack  of  clearness  in  the  pronunciation  of  the  linguo- 
palatals,  and  it  turns  ''  p  "  and  "  b  "  into  the  nasal  resonant  "  m."  When 
the  palate  is  fully  palsied  it  hangs  loosely  in  the  pharynx  without  reflex 
action  or  voluntary  movement.  As  it  can  no  longer  shut  off  the  nasal 
spaces,  fluids  often  regurgitate  through  the  nose,  and  even  food  masses 
may  be  forced  into  the  nasal  fossae. 

When  the  pharynx  is  involved,  the  difficulties  of  swallowing  reach 
their  maximum.  Food  is  now  prone  to  enter  the  respiratory  tract  and 
a  violent  fatiguing,  and  alarming  cough  is  often  produced.  The  danger 
of  pulmonary  engorgement,  aspiration  pneumonia,  and  heart-failure  is 
intensified  by  the  pneumogastric  weakness  that  is  often  present.  Alimen- 
tation becomes  so  difficult  that  the  esophageal  tube  must  be  used  or  the 
patient  must  be  fed  by  the  bowel.  To  these  difficulties  is  added,  sooner 
or  later,  a  paralysis  of  the  larynx.  The  adductors  are  usually  most 
afl^ected  and  the  glottis  stands  wide  open,  serving  neither  the  purposes 
of  phonation  nor  protection  to  the  trachea  against  the  entrance  of  foreign 
material.  In  very  rare  cases  unilateral  or  bilateral  abductor  palsy  is 
found,  and  in  the  latter  case  inspiratory  stridor  indicates  the  dangerous 
respiratory  difficulty.  Both  pharyngeal  and  laryngeal  reflexes  are 
abolished.  The  voice  is  extinguished.  Failing  respiratory  and  cardiac 
actions  lead  to  a  fatal  termination,  which  may  come  suddenly  at  any 
period  of  the  disease.  It  is  often  induced  by  aspiration  pneumonia  or 
caused  by  suffocation  due  to  blocking  of  the  respiratory  passage  by  a 
mass  of  food. 

The  pulse  is  likely  to  become  frequent,  weak,  and  irregular.  True 
anginal  attacks  are  not  infrequent.  Syncope  may  occur  and  prove  fatal. 
The  pneumogastric  involvement  further  shows  itself  in  a  feebleness  of 
respiration,  so  that  coughing  and  other  active  expiratory  efforts  become 
almost  impossible,  adding  greatly  to  the  danger  of  choking  and  to  the 
general  discomfort  of  the  patient.  It  is  somewhat  remarkable  that 
polyuria  and  glycosuria  are  seldom  encountered.  The  controlling 
centers  in  the  bulb  are  in  close  proximity  to  those  invaded  by  this 
disease.  It  will  be  noticed  that  the  nuclei  selected  are  purely  motor  and 
trophic,  and  that  the  disease  spreads  not  so  much  by  contiguity  as  along 
lines  of  associated  function.  This  is  one  of  the  distinctive  habits  of  the 
disease,  and  serves  here,  as  in  other  progressive  maladies  of  the  cerebro- 


MULTIPLE  PARALYSES  OF  CRANIAL   NERVES.  155 

spinal  axis,  to  draw  earnest  attention  to  this  factor  in  the  study  of  every 
case. 

The  electrical  examination  of  the  atrophic  muscles  presents  consider- 
able difficulty,  excepting  in  the  lower  face  and  the  masseters.  The 
changes  found  are  practically  a  quantitative  reduction  to  all  currents  as 
fiber  after  fiber  disappears.  Tlie  reaction  of  degeneration  is  wanting. 
The  reflexes  are  correspondingly  diminished  and  abolished,  excepting  in 
those  cases  in  which  the  disease  early  involves  the  pyramidal  tracts. 
Sensation  is  not  markedly  aifected,  uor  is  the  sense  of  taste  notably  dis- 
turbed in  pure  cases.  The  temperature  remains  uninfluenced  through- 
out, save  by  intercurrent  accidents. 

Course. — The  disease  is  one  of  insidious  onset  and  its  steadily  progres- 
sive course  is  characteristic.  In  a  few  exceptional  cases  the  progress  of  the 
disease  presents  intermissions,  but  remissions  are  practically  unknown. 
The  duration  of  the  malady  from  inception  to  fatal  termination  may  be 
roughly  stated  as  from  one  to  five  years.  Leyden  reports  one  case  of 
seven  years'  duration,  but,  on  the  other  hand,  intercurrent  maladies  and 
the  suffocative,  cardiac,  and  pulmonary  accidents  to  which  the  disease 
lays  the  patient  liable  may  cut  life  short  at  any  moment.  The  increas- 
ing feebleness  and  malnutrition  at  the  same  time  add  to  the  gravity  of 
the  situation.  As  above  indicated,  the  disease  first  manifests  itself  in 
the  tongue  and  progressively  invades  the  lips,  pharynx,  palate,  masti- 
cators, and  larynx.  This  is  a  usual  sequence,  but  not  a  necessary  one. 
Any  modification  of  it  may  be  presented.  The  encroachments  of  related 
nuclear  disease  at  lower  and  higher  levels  give  rise  to  different  trains 
of  symptoms,  which,  however,  in  their  full  development  furnish  very 
similar  pictures.  The  course  pursued  in  any  given  case  can  be  under- 
stood by  reference  to  the  anatomical  and  especially  to  the  functional 
relationship  of  the  bulbar  nuclei.  The  occurrence  of  a  bronchitis, 
bronchopneumonia,  angina  pectoris,  or  of  suffocative  attacks  is  often  of 
fatal  import. 

Diagnosis. — The  diagnosis  of  a  well-developed  and  unmixed  case 
presents  little  difficulty.  The  course  of  the  disease  is  of  the  first  impor- 
tance. The  facies  can  hardly  be  mistaken.  Palsy  of  both  facial 
nerves  gives  rise  to  feebleness  of  the  lips,  but  the  upper  part  of  the  face 
does  not  escape  and  glossopharyngeal  symptoms  are  lacking.  Diph- 
theric palatal  palsy  may  raise  a  doubt  unless  the  clinical  history  of  the 
infection  is  available.  In  this  condition  the  lips  and  tongue  escape,  the 
onset  is  somewhat  abrupt,  and  the  usual  course  is  toward  recovery. 
Great  difficulty  may  be  presented  in  cases  of  multiple  neuritis,  but  in 
them  we  have  sensory  disturbances,  the  reaction  of  degeneration,  and 
marked  symptoms  in  the  extremities.  When  secondary  to  tabes,  insular 
sclerosis,  syringomyelia,  and  amyotrophic  lateral  sclerosis,  the  highly 
characteristic  symptoms  of  these  various  diseases  are  prominent.  As 
an  extension  process  from  the  cord  upward,  or  from  the  ocular  nuclei 
downward,  its  development  is  preceded  by  the  well-marked  evidence 
of  these  prior  states,  which  persist  and  increase  during  the  evolution  of 
the  bulbar  paralysis.  The  greatest  diagnostic  difficulty  is  presented  by 
cases  of  the  pseudobulbar  paralyses. 


156  DISEASES  OF  THE   CRANIAL  NEBVES. 

Treatment. — In  pure  polio-encephalitis  inferior  chronica  the  prog- 
nosis is  fatal.  Curative  treatment  is,  therefore,  out  of  the  question, 
but  much  can  be  done  to  alleviate  the  distressing  condition  of  the 
patient  and  to  obviate  the  laryngeal,  pulmonary,  and  nutritive  dan- 
gers that  threaten  him  with  suffocation,  asphyxiation,  pneumonia,  and 
inanition.  The  hypersecretion  of  saliva  may  be  checked  by  atropin, 
which  also  furnishes  a  reliable  heart-stimulant.  The  stomach-tube  and 
rectal  alimentation  are  our  means  to  avoid  strangulation  and  to  secure 
nutrition.  Recourse  to  tracheotomy  may  be  had  in  abductor  laryngeal 
paralysis.  Electricity  is  of  use  in  exercising  the  muscles  of  the  face, 
tongue,  and  gullet.  The  faradic  current  is  sufficient.  The  large,  indif- 
ferent electrode  may  be  placed  on  the  back  of  the  neck,  and  a  smaller, 
active  electrode  is  then  brought  into  contact  with  the  lips,  masseters,  and 
tono-ue.  By  placing  it  over  the  pomum  adami  swallowing  efforts  are 
induced.  Care  must  be  exercised  not  to  fatigue  muscles  already  wasted. 
Energetic  courses  of  silver,  ergot,  phosphorus,  zinc,  picro toxin,  and 
mercury  are  mentioned  only  to  condemn  them,  and  anything  else  that 
pulls  down  the  waning  strength  of  tlie  patient  must  be  avoided.  Tonics, 
rest,  and  strengtheniug  measures  are  of  value. 

Acute  bulbar  palsy,  or  acute  bulbar  myelitis,  is  due  to  the  same 
infections  that  set  up  acute  myelitis.  It  may  furnish  the  terminal  stage 
of  the  chronic  form,  or  it  may  result  frOm  an  upward  extension  of  a 
cord-lesion.  The  symptoms  with  which  we  are  familiar  in  the  chronic 
variety  are  rapidly  evolved  and  often  associated  with  febrile  disturb- 
ances, headache,  and  somnolence.  As  the  disease  gains  the  pneumo- 
gastric  nuclei,  death  becomes  imminent  and  results  through  respiratory 
failure. 

Combined  Forms  of  Polio-encephalitis. — The  various  combi- 
nations of  chronic  superior  and  inferior  polio-encephalitis  by  extension 
have  been  alluded  to  in  describing  them  separately.  In  some  very  rare 
cases  the  nuclear  invasion  falls  upon  upper  and  lower  cranial  nuclei 
practically  at  once.  The  resulting  picture  is  an  aggregate  of  the  simpler 
ones.  From  their  vital  nature,  the  presence  of  pneumogastric  symptoms 
dominates  the  outlook. 

Pseudobulbar  Paralyses. — These  are  (1)  organic  and  (2)  asthe- 
nic. The  organic  variety  is  due  to  more  or  less  symmetrical  lesions 
involving  the  posterior  group  of  cranial  nerves  at  any  point  from  their 
cortical  centers  to  their  peripheral  trunks.  We  distinguish  a  cerebral 
form  due  to  bilateral  cortical  or  subcortical  vascular  lesions.  The  onset 
is  abrupt,  and  usually  developed  in  two  stages.  A  hemiplegic  or  apo- 
plectic case  presents  a  second  stroke,  this  time  from  a  lesion  in  the  sound 
hemisphere,  and  the  bulbar  palsy  is  at  once  established  or  completed. 
It  is  only  very  rarely  limited  to  the  parts  definitely  elected  by  true 
bulbar  palsy,  does  not  present  the  atrophy  or  degenerative  reactions,  and 
the  reflexes  are  retained  or  exaggerated.  A  radicular  form  follows  acute 
bulbar  myelitis  and  hemorrhage  into  or  softening  of  the  bulb.  These 
are  rare  affections  of  sudden  onset.  The  lesion  does  not  spare  the  motor 
tracts  for  the  limbs,  and  other  bulbar  functions  do  not  escape.  Tumor 
may  similarly  produce  a  pseudolnilbar  palsy,  but  the  distinctive  symp- 


MULTIPLE  PAEALYSES  OF  CRANIAL  NERVES.  157 

toiiis  of  an  intracranial  growth — headaches,  vomiting,  vertigo,  and  pap- 
ilhtis — are  added.  A  bimlw  form  is  occasioned  by  tumors  of  the  base 
and  basilar  meningitis,  especially  of  the  syphilitic  variety.  A  pseudo- 
bulbar paralysis  of  this  form  is  among  the  greatest  rarities,  for  obvious 
anatomical  reasons.  Finally  we  have  a  neuritic  form.  This  is  usually 
only  a  part  of  a  more  widely  distributed  or  multiple  neuritis. 

Asthenic  Bulbar  Paralysis  [Myasthenia  Gravis). — This  disorder, 
as  described  by  Striimpell,  ^  may  mimic  chronic  polio-encephalitis  in- 
ferior very  closely.  Previous  to  his  communication  a  similar  case  was 
reported  by  Jolly, ^  under  the  title  of  ^''Myasthenia  Gravis  Pseudo- 
paralytica,"  but  is  never  so  closely  limited  to  the  cranial  nerve.  Since 
that  time  cases  have  been  reported  by  Murri,^  Pineles,^  Bruns,^ 
Collins,^  Hallervorden, '^  KojewnikoflP, ^  and  many  others. 

The  condition  in  several  instances  has  terminated  fatally,  but  no 
changes  in  the  bulbar  nuclei  were  discovered.  Apparently  the  deficit 
or  toxic  effect  had  not  reached  a  degree  sufficiently  intense  to  produce 
cell-changes  that  were  observable  under  ordinary  methods  of  examina- 
tion. In  a  case  reported  by  Widal  and  Marenesco,  ^  disintegration  of 
the  chromophilic  elements  was  demonstrated  by  the  Nissl  and  Marchi 
methods.  Goldflam  ^  ^  found  widespread  and  decided  changes  in  the 
muscles.  This  case  and  one  reported  by  Long  and  Wicki  presented 
preceding  chronic  pulmonary  septic  conditions.  Laquer  and  Weigert 
have  also  noted  widespread  changes  in  the  muscles  apparently  secondary 
to  thymus  disease.  Laquer  reports  a  case  followed  by  progressive 
spinal  muscular  atrophy.  Senator  i  ^  suggests  a  relationship  to  various 
depraved  blood  states.  Remak  refers  to  a  case  of  associated  Graves' 
disease.  Feinberg  reports  a  case  in  which  stercoremia  was  present  and 
the  asthenic  symptoms  retreated  upon  its  relief. 

The  paralysis,  which  comes  on  more  or  less  insidiously,  especially 
involves  the  tongue,  lips,  and  pharynx,  but  the  eyes  and  extremities  are 
also  affected  to  a  certain  degree.  Ptosis  is  commonly  encountered  early. 
Usually,  indeed,  the  myasthenia  is  general.  Fibrillary  twitching  is 
wanting,  and  the  reflexes  are  not  disturbed.  ^  ^  Electrical  responses  are 
only  modified  by  the  fatigue  induced  by  their  repetition,  presenting  the 
myasthenic  reaction,  especially  to  the  faradic  current.  It  is  found,  as 
in  bulbar  paralysis,  that  rest  seems  to  improve  the  paralytic  features,  but 
that  the  muscles  involved  show  an  extraordinary  susceptibility  to 
fatigue.  Jolly's  case  showed  ready  muscular  exhaustion  under  electrical 
stimulus,  and  this  has  been  found  in  some  other  cases.  ^^  In  some 
instances  there  is  a  tendency  to  improve  and  to  relapse,  as  in  the  case 
of  Collins,  in  which  case  the  special  senses  of  sight  and  hearing  also 
showed  rapid  exhaustion. 

1  "Deut.  Zeit.  f.  Nervenheilk.,"  Bd.  8. 

2  "Berlin,  klin.  Wochens.,"  Jan.  7,  1895.  «  "  Policlinico, "  vol.  ii,  1895. 
*  "Wien.  Jahrbnch  f.  Psyehiat.,"  vol.  xiii.         ^Schmidt's  "  Jahrbuch, "  1896. 

^  "Internat.  Med.  Mag.,"  April,  1896.  "^  "Archiv  f.  Psychiatrie, "  vol.  xxviii. 

8  "Dent.  Zeit.  f.  Nervenheilk.,"  Nov.,  1896.       »  "Presse  ined.,"  April  14,  1897. 
1"  "Neurol.  Central bl.,"  Feb.  1,  1902. 
11  "Berlin,  klin.  Wochens.,"  1899. 

i^Oppenheim,  "Mvesthenische  Paralyse,"  Berlin,  1901. 
13  Buzzard,  "British  Med.  Jour.,"  March  3,  1900. 


158  DISEASES  OF  THE  CRANIAL  NERVES. 

The  condition  is  marked  essentially  by  asthenia,  affecting  particularly 
the  motor  apparatus.  The  prognosis  is  grave,  as  a  fair  proportion  of 
the  cases  terminate  fatally  through  asphyxia.  In  the  treatment,  rest 
and  the  free  administration  of  strychnia  are  advised  with  correction  of 
any  toxic  or  septic  factor  that  may  be  discovered. 


PABT  III. 

DISEASES  OF  THE  BRAIN  PROPER. 


CHAPTER  I. 
THE  CEREBRAL  CORTEX— LOCALIZATION* 

General  Considerations. — The  subject  of  localization  of  function  in 
the  cerebral  cortex  has  attained  great  importance  and  its  literature  \'ast 
proportions.  The  practical  considerations  will  be  briefly  and  somewhat 
dogmatically  set  forth.  Many  points  are  still  under  debate,  awaiting 
further  experience  and  experiment,  and  some  of  these  problems  it  is 
likely  will  never  reach  solution.  It  is  well  determined  that  there  is  a 
definite  area  of  the  cortex  that  is  closely  associated  with  motor  func- 
tions. That  this  zone  is  purely  motor  is  open  to  serious  question.  The 
general  trend  of  belief  is  that  it  is  also  sensory,  at  least  in  part,  and  that 
motion  does  not  even  originate  in  it.  As  a  working  scheme  we  may 
consider  that  motion  is  represented  in  three  levels  :  First,  in  the  gray 
matter  of  the  spinal  cord  ;  second,  in  the  Rolandic  area  of  the  cortex  ; 
third,  in  the  highest  level  of  conscious  thought,  probably  in  the  frontal 
region  of  the  brain.  The  spinal  level  may  be  considered  that  of  reflex, 
vegetative  automatism,  the  Rolandic  level  that  of  motor  memories,  and 
the  frontal  area  that  of  conscious,  selective,  and  intelligent  action.  Thus, 
destruction  of  the  highest  level  leaves  automatic  and  memory  action 
practically  unimpaired,  as  in  the  experiments  of  Goltz,  who  removed 
the  entire  cerebrum  of  dogs  without  depriving  them  of  muscular  motion 
or  bodily  function.  In  the  automatism  of  dementia  the  motor  memories 
are  likewise  preserved.  The  mid-level,  the  Rolandic  region,  may  be 
destroyed,  leaving  consciousness  of  volitional  motions  and  the  will  to 
execute  them,  but  the  memory  of  their  muscular  production  is  gone,  and 
they  default,  as,  for  instance,  in  motor  aphasia.  If  the  lowest  or  spinal 
level  be  destroyed,  the  mind  and  the  memory  organ  have  lost  their  tool 
and  peripheral  paralysis  obtains.  There  is  no  difficulty  in  conceiving 
certain  cortical  areas  to  be  memory  organs,  as  in  the  case  of  the  higher 
visual  centers  in  the  parietal  lobe.  We  may,  however,  go  further.  All 
thought  contains  the  two  ideas  of  motion  and  sensation.  They  can  not 
be  separated,  and  without  them  consciousness  is  impossible.  Indeed, 
they  are  in  a  certain  sense  identical.  Motion  is  to  the  mind  but  the  sen- 
sation of  a  change  of  position,  and  sensation  is  only  the  recognition  of 

159 


160  DISEASES  OF  TEE  BRAIN  PROPER. 

arrested  motion.  If,  then,  we  consider  the  parietal  convolutions  as 
visual  memory  depots,  we  are  equally  at  liberty  to  consider  the  Rolandic 
areas  as  motor  memory  depots.  The  flutist,  by  laborious  conscious 
eifort,  establishes  motor  memories  in  his  central  gyri  which  can  subse- 
quently be  called  into  operation  by  the  will  with  a  rapidity  of  which 
conscious  thought  is  incapable.  The  new-born  child  can  hardly  direct 
its  hand  to  its  face,  but  very  rapidly  develops  coordinate  motor  mem- 
ories of  this  act  in  the  motor  cortex  that  thenceforward  are  easily  re- 
called or  subconsciously  repeated.  In  the  spinal  levels  single  muscles  or 
groups  of  muscles  are  represented.  In  the  motor  cortex  co5rdinate  and 
functionally  associated  movement  memories  are  located,  and  in  the  highest 
level  resides  their  volitional  control  and  the  power  to  recall  and  select 
them. 

If  these  propositions  are  true  in  any  degree,  we  would  expect  a  neigh- 
boring relation  of  motion  and  sensation  in  the  cortical  representation, 
and  this  is  no  doubt  the  case.  Horsley  believes  them  to  be  superim- 
posed in  strata,  (1)  most  superficially  tactile  sense,  then  (2)  muscular 

sense,  and  finally  (3)  pure  motor  elements  below. 
Q  Tactile  sense.         This  is  Confirmed  by  clinical  experience  in  cases 

of   endarterial  thickening,  by   which  the   blood- 
^  ,,      ,  supply  of  the  cortex  is  reduced.     In  such  cases 

Muscular  sense.  -,  -..-,,       r^        .  -, 

^  due  to  syphilis  for  instance,  as  the  endarteritis 

comes  on  or  recedes  the  sensory  disturbance  and 
Pure  motion.         paresthetic    complaints   are   prominent.      This    is 
due  to  the  arrangement  of  the   cortical  vessels. 
Arising  from  considerable  arteries  in  the  arach- 
nopia,  we  have  first  a  system  of  short  capillary 
Fig.  66,-Horsiey's  view    ^'^sscls  that  uourish  the  cortex,  and  especially  its 
of  the  sensorimotor  repre-    superficial  or  scusorv  lavcrs,  and,  second,  a  system 

sentatiou  m  the  motor  cor-  ^  "         "         i        i  ^ 

tex.  01  longer  and  larger  vessels  that  penetrate  to  the 

white  matter  without  giving  branches  to  the  super- 
ficial cortex,  but  which  do  in  part  supply  its  deeper  layers.  It  is  at  once 
evident  that  as  the  circulation  fails  the  superficial,  small,  narrow,  cor- 
tical vessels  will  first  suffer.  Hence  we  have  sensory  prodromata  and 
sensory  remnants  in  such  diseases  of  the  cortical  arteries  in  proportion  as, 
and  because,  the  superficial  or  sensory  strata  of  the  cortex  are  mainly 
atfected.  There  are  numerous  conflicting  cases,  ably  marshaled  in  this 
country  by  Dana  and  Mills  on  opposite  sides,  in  which  cortical  disease 
in  the  Rolandic  area  was  or  was  not  attended  by  sensory  disturbance  in 
the  corresponding  motor  periphery.  The  writer  has  to  declare  that  he 
has  never  carefully  examined  a  case  of  gross  disease  of  the  motor  cortex 
without  finding  some  related  sensory  disturbance.  It  probably  will  be 
found  temporary  or  permanent  as  it  encroaches  upon  or  aifects  the  sensory 
layers  of  the  cortex.  It  is  more  than  probable  that  sensation  is  repre- 
sented bilaterally  in  the  cerebral  cortex  more  completely  than  unilateral 
motion,  and  is  consequently  less  modified  by  one-sided  cerebral  disease. 
The  inharmonious  views  variously  entertained  relative  to  sensory 
depots  in  the  cortex  may  be  reconciled  if  we  consider  the  sensorimotor 
zone  as  a  midwav  station  for  sensation  as  well  as  motion  and  conceive 


THE  CEREBRAL  CORTEX— LOCALIZATION. 


161 


of  a  higher  cortical  sensory  level.  There  is  a  growing  amount  of 
material  pointing  to  the  parietal  lobe  as  the  seat  of  the  so-called  stereog- 
nostic  sense,  a  complex  faculty  which  is  disturbed  by  lesions  of  the 
superior  portion  of  this  lobe,  often  with  mind-blindness  in  association 
when  left-sided. 

The  cortex  is  anatomically,  or  rather  histologically,  divided  into 
from  three  to  eight  layers  by  various  investigators.  The  important  fact 
is  brought  out  by  all  that  the  superficial  layers  are  granular,  and  that 
the  cells  become  progressively  larger  and  more  completely  differentiated 
as  we  descend,  until,  in  the  lower  strata,  the  cells  correspond  in  appear- 
ance to  the  multipolar  pyramidal  elements  of  the  motor  horns  in  the 
spinal  cord.  The  cortical  cells  are  practically  all  present  at  birth,  and 
the  development  and  growth  of  the  brain  depends  mainly  upon  the  in- 
crease in  their  dendritic  processes  and  the  fibrous  feltwork  that  supports 
them.  It  is  now  generally  believed  that  the  interrelation  of  these  cells 
is  due  not  to  actual  continuity  of  their  processes,  but  merely  to  their 
interlacing  and  apposition.  The  conditions,  apparently,  which  best  favor 
the  transmission  of  nervous  influence  and  the  functioning  of  nerve-cells 
would  be  close  filamentous  apposition.  Withdrawal  of  contact  might 
serve  as  an  insulating  and  inhibiting  measure,  a  theory  strongly  supported 
in  some  quarters,  but  as  yet  only  a  theory.  The  nuclei  of  these  cells  are 
now  considered  as  only  dominating  their  nutrition,  and  not  otherwise 
essential  to  their  activity,  which  is  relatively  the  same  at  the  dendritic 
periphery  as  in  the  cell-body. 


Fig.  67.— Scheme  to  represent  the  cortical  arterial  circulation,  apm,  Artery  of  the  pia  mater; 
AC,  short  arteries  to  the  gray  matter  only;  al,  long  arteries  penetrating  the  white  substance  (after 
Brissaud). 


Movements  dependent  upon  paired  muscles,  such  as  those  of  the 
trunk,  are  rarely  abolished  by  unilateral  brain  disease.  Those  of  a 
specialized  and  one-sided  character,  however,  may  be  completely  inhib- 
ited by  unilateral  disease  of  their  memory  centers.  Thus,  the  frontalis  is 
rarely  affected  in  cortical  hemiplegia,  while  the  unilaterally  acting  mus- 
cles of  the  lower  part  of  the  face  are  usually  paretic  in  this  condition. 
11 


162  DISEASES  OF  THE  BRAIN  PROPER. 

It  is  an  acceptable  proposition  that  all  skeletal  muscular  activity  is  bi- 
laterally represented,  and  it  is  also  true  that  all  unpaired  muscles  and 
their  coordinate  activities  are  more  particularly  controlled  by  the  oppo- 
site half-brain.  The  acquired  faculty  of  speech,  however,  and  the  nu- 
merous motor  and  sensory  memories  associated  with  it,  are  almost  always 
mainly  represented  in  the  left  cortex  in  right-handed  individuals.  The 
superior  weight  and  development  of  the  left  half-brain  is  probably 
largely  attributable  to  its  better  nutritive  supply  through  the  arrangement 
of  the  vessels  at  the  aortic  arch  and  the  larger  caliber  of  the  left  carotid. 
This  induces  right-handedness,  which  in  time,  no  doubt,  retroactively  in- 
creases the  functional  activity  of  the  left  cortex.  At  the  same  time 
the  left  hemisphere  becomes  potentially  greater,  more  acquisitive,  and 
therefore  largely  the  seat  of  acquired  motor  and  sensory  education,  which 
in  turn  increases  its  growth.  It  is  probable  that  some  overflow  occurs 
in  most  brains,  so  that  automatic  emotional  and  expletive  expressions 
either  come  to  be  located  in  the  right  brain  or  their  frequent  repetition 
sufficiently  educates  the  right  cortex  to  enable  them  to  be  recalled 
through  its  agency  when  the  left  centers  are  cut  off.  Similarly,  if  speech 
control  be  lost  to  the  left  half-brain,  the  right,  especially  in  young  per- 
sons, may  be  in  turn  educated  to  take  its  place  in  large  measure.  It  is 
worthy  of  consideration  whether  the  whole  conscious  and  unconscious 
tendency  of  education,  habit,  custom,  and  practice  to  make  all  men  right- 
handed  is  not  a  serious  mistake.  It  seems  plausible  that  should  left- 
handedness,  or  rather  ambidexterity,  be  assiduously  cultivated  in  chil- 
dren, the  two  hemispheres  of  the  brain  might  enjoy  a  greater  equality 
and  the  individual  secure  not  only  amplified  muscular  control,  but  a 
certain  lessened  liability  to  aphasia  and  hemiplegic  losses. 

Motor  Cortical  Localization. — The  human  cerebral  motor  cortex 
has  been  mapped  out  with  fair  uniformity  by  numerous  investigators. 
Following  the  lines  laid  down  by  Ferrier,  Schaefer,  and  Horsley,  origi- 
nally based  upon  experiments  on  the  monkey,  the  results  of  focal 
lesions  in  man  and  actual  stimulation  of  the  human  cortex  by  elec- 
tricity have  given  a  fair  degree  of  precision  to  the  outlines  of  what 
I  have  ventured  to  call  the  motor  memory  area.  Comparing  fig- 
ures 66  and  67,  we  may  see  that  all  skeletal-muscle  groups  are  rep- 
resented. Such  outlines  must  be  taken  as  suggestive  rather  than  actual. 
There  is  no  sharp  boundary  between  the  adjoining  centers,  and  these 
fields  overlap.  The  dippings  of  the  sulci  also  serve  to  interfere  with 
sharp  limitations  of  the  cortical  areas  and  obstruct  the  experimental 
stimulation  of  individual  movements.  Every  muscular  movement,  ap- 
parently, has  a  locus  of  principal  or  major  representation  in  the  cortex, 
but  such  a  movement  is  so  wrapped  up  with  other  coordinate  movements, 
and  so  widely  related  functionally,  that  its  representation  in  a  minor  de- 
gree may  spread  over  great  areas.  The  thumb,  for  instance,  is  princi- 
pally represented  in  a  given  small  cortical  center,  but  the  prehensile 
action  of  the  thumb  is  related  to  the  grasp  of  the  fingers,  the  fixation 
of  the  wrist,  the  rigidity  of  the  whole  upper  extremity,  and  even  to 
action  of  the  trunk  and  lower  limbs  in  strongest  efforts,  during  which 
the  opposite  members  also  come  into  play. 


THE  CEREBRAL  CORTEX— LOCALIZATION. 


163 


Beginning  at  the  l)raiic]iing  of  the  Sylvian  fissure,  Ave  have,  in  the 
lowest  and  hindermost  portion  of  the  third  frontal  convolution,  the 
movements  of  the  tongue.     Adjoining  these  caudad,  on  the  lowest  por- 


Fig.  68. — Functional  areas  of  the  cerebral  cortex  ou  the  left  side  (Derciim). 

tion  of  the  ascending  gyri,  we  find  the  platysma  represented  with 
the  lower  face  muscles,  and  then,  above  and  on  both  sides  of  the  fissure 
of   E,olando,  the   upper  face   movements.      In  front  of  the  ascending 


Fig.  69.— Functional  areas  of  the  cerebral  cortex  on  the  right  side  (Dereum). 


frontal  gyre,  occupying  the  rearmost  portion  of  the  second  frontal  con- 
volution, is  an  area  that  is  associated  with  conjoint  movements  of  the 
head  and  eyes  to  the  opposite  side.     According  to  Mott,  stimulation  of 


164 


DISEASES  OF  THE  BRAIN  PROPER. 


the  lower  portion  of  this  area  in  monkeys  causes  the  head  and  eyes  to 
turn  to  the  opposite  side  and  upward.  Stimulation  of  the  middle 
portion  causes  the  head  and  eyes  to  turn  in  the  horizontal  plane 
to  the  opposite  side,  and  stimulation  of  the  upper  third  of  this  field 
directs  the  eyes  and  head  to  the  opposite  side  and  downward.  It  is 
probable  that  similar  differentiation  exists  in  the  head-and-eyes  territory 
in  man.  Roux^  von  Bechterew,  and  others  assert  that  there  is  a  some- 
what similar  center  near  the  anterior  margin  of  the  occipital  lobe,  not 
distant  from  the  visual  speech  memory  depots,  that  also  controls  the 
pupillary  and  ciliary  movements  in  accommodation  (see  p.  104). 

Above  the  face  area  we  find  the  upper  extremity  represented.  This 
area  occupies  the  middle  portion  of  both  ascending  gyri  and  is  bounded 
in  front  by  the  centers  for  the  head  and  eyes.  From  below  upward  we 
note  that  the  movements  correspond  in  location  to  those  of  the  opposite 
member  as  if  it  had  been  reached  over  the  vertex  and  applied  in  fore- 
shortened miniature  to  the  cortex.  Thus,  in  order  from  below  and  be- 
hind, upward  and  forward,  we  find  successively  represented  the  motions 
of  tlie  digits,  thumb  to  the  rear,  wrist,  elbov),  and  shoulder. 

Lying  above  the  upper  extremity  centers  are  those  for  the  lower 
extremity.  They  occupy  the  caudad  portion  of  the  first  frontal  gyre  to 
a  slight  extent,  and  the  upper  ends  of  both  ascending  convolutions  at  the 
vertical  margin  of  the  half-brain,  over  which  they  lap  onto  its  median 
surface  as  low  as  the  callosomarginal  fissure.  The  thigh  movements  are 
anterior,  followed  in  order,  just  as  in  the  extremity  itself,  by  those  for 
the  leg,  foot,  and  toes,  with  the  gr-eat  toe  last  of  all  and  to  the  rear. 

Above  the  centers  for  the  head  and  eyes, 
and  in  front  of  those  for  the  lower  extremity, 
are  represented  the  trunkal  movements.  This 
area  is  relatively  small,  as  these  movements  are 
simple  and  coarse  in  comparison,  for  instance, 
with  those  of  the  face  and  fingers.  It  occupies 
the  posterior  portion  of  the  first  frontal  con- 
volution, and  laps  over  onto  the  median  surface 
of  the  hemisphere.  It  is  bounded  caudad  by 
the  thigh  area. 

If  we  take  the  Rolandic  area,  from  the  su- 
perior margin  of  the  half-brain  to  the  Sylvian 
fissure,  and  divide  it  into  fifths  by  horizontal 
parallel  lines,  the  face  occupies  the  lowest  two- 
fifths,  the  upper  extremity  the  next  two-fifths, 
and  the  lower  extremity  the  highest  and  re- 
maining fifth. 

Near  the  center  for  the  platysma,  which 
retracts  the  angles  of  the  mouth,  and  in  front 
of  it,  we  find,  in  the  lowermost  portion  of  the 
ascending  frontal  gyre,  the  movements  of  mastication,  and  those  for  the 
lips,  the  pharynx,  and  the  larynx.  In  front  of  this,  in  the  third  or  lowest 
frontal  convolution,  or  Broca's  convolution,  are  located  the  memories  of 
motor  speech.  These  are  confined  to  the  left  hemisphere  in  right-handed 
persons,  and  usually  to  the  right  half-brain  in  the  left-handed. 


Fig.  70. — Relations  of  body  to 
cortical  areas. 


THE  CEREBRAL  CORTEX— LOCALIZATION.  165 

Sensory  Cortical  Localization. — The  impossibility  of  accurately 
detcruiiniug  sensoiy  disturbances  iu  aniaials  is  one  of  the  major  reasons 
for  the  confusion  that  exists  regarding  the  cortical  representation  of  this 
function.  At  present,  however,  no  one  claims  that  the  motor  cortical 
area  is  entirely  devoid  of  participation  in  the  receipt  of  afferent  impulses. 
Mills  reaffirms  his  belief  that  the  limbic  lobe  and  quadrate  lobule  are 
essentially  sensory,  and  Dana  admits  that  they  may  be  so,  but  that  the 
motor  area  is  also  sensory,  or,  rather,  sensorimotor.  The  essential  unity 
of  motion  and  sensation  has  been  already  insisted  upon  in  the  general 
consideration  of  this  subject,  and  the  sensory  mechanism  in  the  super- 
ficial cortical  layers  has  been  pointed  out.  The  probability  of  complete 
bilateral  representation  of  sensation  as  a  usual  condition  and  the  equality 
of  the  hemispheres  in  this  relation  have  been  adverted  to.  It  would  seem 
supposable  that  the  sensorimotor  zone  may  be  an  intermediate  or  memory 
depot  for  sensation,  as  it  is  for  motion,  and  that  there  are  higher  psychi- 
cal levels,  which  may  be  in  the  limbic  lobe,  as  we  have  higher  visual 
centers  in  the  parietal  lobe.  At  least  we  have  the  valuable  clinical  fact 
that  in  patients  with  brain  injury  the  presence  of  stereoagnosis  points 
to  a  lesion  of  the  quadrate  lobule  above  the  area  for  visual  speech. 
We  should  keep  in  mind  that  what  is  recognized  as  a  sensation  is  the 
appreciation  of  arrested  motion.  We  may  thus  conceive  auditory  sen- 
sation as  the  recognition,  through  the  mechanism  of  the  ear,  of  the 
arrest  of  sound-waves ;  visual  sensations,  as  the  recognition  of  the 
impact  or  contact  with  the  retina  of  luminous  waves,  or  light  vibrations. 
The  special  senses  of  smell  and  taste  are  clearly  dependent  upon  the 
contact  of  odorous  quantities  and  sapid  particles.  It  is  always  contact, 
always  arrested  motion,  always  touch.  Regarding  the  location  in  the 
cortex  o^  general  sensation  and  its  immediate  modifications,  the  tactile, 
muscular,  pain,  and  temperature  senses,  we  are  still  in  the  mazes  of 
speculation.  The  cortical  relations  of  certain  of  the  so-called  special 
senses  are  more  definite. 

Vision. — The  optic  radiations  arising  from  the  outer  geniculate  body 
and  in  the  neighborhood  of  the  quadrigemina  stream  backward  into  the 
occipital  lobe  and  reach  the  cortex  at  its  apex.  It  may  now  be  accepted 
that  half-vision  is  represented  at  this  location, — namely,  that  the  corre- 
sponding half  of  each  retina  is  subserved  by  the  occipital  cortex  of  the 
same  side.  The  investigations  of  Henschen  and  others  indicate  that  the 
macula  is  represented  in  each  occipital  cortex  in  more  or  less  complete 
degree.  It  thus  results  that  ablation  or  destruction  of  one  occipital  lobe 
produces  double  homonymous  hemianopsia.  In  this  condition  the  macula 
is  regularly  spared,  as  it  is  sufficiently  supplied  by  the  opposite  lobe.  It 
is  likely  that  the  half-retina  may  be  further  divided  into  irregular  and 
varying  upper  and  lower  quadrants,  with  localized  cortical  representation. 
It  is  indicated  by  some  clinical  cases  that  the  fibers  in  the  optic  radiation 
which  serve  the  upper  quadrants  are  above  those  for  the  lower,  and  that 
the  macular  fibers  are  placed  between  them.  Altogether  they  make  a 
bundle  about  a  centimeter  thick,  passing  horizontally  backward  at  the 
level  of  the  second  temporosphenoidal  gyre.  They  finally  reach  the 
apical  occipital  cortex,  and  seem  to  have  their  maximum  field  in  the 


166  DISEASES  OF  THE  BRAIN  PROPER. 

neighborhood  of  the  calcarine  fissure  on  the  mesial  surface  of  the  lobe, 
over  all  of  which  half-vision  is  represented  to  some  extent. 

Higher  visual  coordinating  and  combining  centers  no  doubt  exist, 
and  probably  are  in  the  angular  gyre  of  the  parietal  lobe,  where  Ferrier 
first  placed  vision  and  where  he  still  believes  the  macular  representation 
is  localized.  This  seems  to  be  the  seat  of  visual  memories.  Memories 
for  printed  speech  are  probably  located  here  in  particular  and  on  the 
left  side  alone.  Destruction  of  the  left  angular  gyre,  therefore,  produces 
word-hlindness  and  destruction  of  both  angular  gyri  produces  mmd- 
blindness,  all  objects  failing  recognition. 

Hearing  is  subserved  by  the  first  and  second  temporal  convolutions, 
which  are  in  relation  with  both  ears.  It,  therefore,  requires  bilateral 
destruction  of  the  gyri  to  produce  complete  cerebral  deafness.  Memories 
of  spoken  words  are  apparently  stored  in  the  posterior  two-thirds  of 
the  first  and  second  temporal  gyri  on  the  left  side.  When  this  area  is 
destroyed,  the  right-handed  patient  becomes  wo7-d  deaf. 

Smell  and  taste  are  presumably  located  in  the  cortex  of  the  median 
surface  of  the  temporal  lobe,  smell  in  the  uncinate  convolution,  and  taste 
below  it  in  the  fourth  temporal.  Broca,  and  after  him  Zuckerkandl, 
located  smell  throughout  the  limbic  lobe,  but  Ferrier  and  later  investi- 
gators are  disposed  to  confine  it  to  the  uncinate  gyre  and  the  hippocampal 
region.  The  recorded  cases  bearing  upon  the  locations  of  smell  and  taste 
are  extremely  few  and  not  convincing.  The  region  is  not  often  aifected 
by  limited  lesions.  A  few  hemiplegics  lose  smell  in  the  nostril  opposite 
a  lesion  which  involves  the  temporal  lobe.  Lesions  of  the  tip  of  the 
temporal  lobe  have  also  been  found  in  epileptics  who  had  a  gustatory 
aura  or  one  of  smell.  Insane  hallucinations  of  smell  have  been  related 
to  disease  in  this  portion  of  the  brain. 

Cortex  of  Unknown  Function. — Examination  of  the  diagrams 
will  at  once  indicate  that  the  cortex  of  unknown  function  is  much  greater 
on  the  right  than  on  the  left  side,  owing  to  the  fact  that  speech  finds  its 
representation  almost  solely  in  the  left  brain.  In  the  prefrontal  area, 
anterior  to  the  so-called  motor  zone,  it  is  customary  to  locate  the  higher 
psychical  functions.  While  it  is  true  that  this  region  may  be  largely  de- 
stroyed by  injury  or  disease  without  producing  localizing  symptoms, 
there  is  a  rapidly  growing  number  of  cases  indicating  that  mental  and 
moral  obliquities  are  usually  the  sequence  of  such  lesions.  Ablation  of 
the  prefrontal  region  in  dogs  and  monkeys  induces  a  change  of  charac- 
ter, of  disposition,  of  behavior,  that  is  clearly  recognizable.  In  men 
with  prefrontal  brain  injury,  mental  sluggishness,  want  of  attention, 
diminished  memory,  loss  of  energy  and  of  self-control,  are  noted  with 
rmore  than  coincidental  frequency.  The  upper  and  posterior  parietal 
regions,  a  portion  of  the  temporal  cortex,  and  the  island  of  Reil  are 
;  still  unaccounted  for.  These  are  known  as  regions  of  latent  lesions — 
tof  lesions  which  do  not  necessarily  produce  symptoms. 

Craniocerebral  Topography. — It  is  very  necessary  in  many  cases 
of  brain  disease  to  locate  the  underlying  cortex,  either  for  the  purpose 
of  operation  or  to  determine  the  relation  of  scalp  wounds,  depressed 
fractures,  and  other  traumata,  to  the  cortex.  No  brain  presents  sym- 
metrical hemispheres,  consequently  we  can  not   expect  a  close  resem- 


THE  CEREBRAL  CORTEX— LOCALIZATION. 


167 


blancc  between  the  brains  of  different  in(livi<bials.  There  are  also 
variations  for  sex,  age,  and  body-weight.  Very  often  there  are  super- 
nnmerary  or  unusual  convolutions  on  one  or  both  sides.  A  number  of 
methods  have  been  devised  by  Reid,  Horsley,  Hare,  and  others,  to  map 
out  on  the  scalp  the  underlying  cortical  areas.  They  all  have  valuable 
features  ;  but  if  you  apply  a  number  of  them  to  the  same  head,  so  im- 
portant a  landmark  as  the  Sylvian  fissure  will  be  variously  defined. 
Absolute  exactness,  for  the  reasons  already  indicated,  is  not  within  the 
range  of  possibility.  AVith  the  formulas  named,  the  difficulty  lies  largely 
in  selecting  rather  indefinite  anatomical  points,  like  the  parietal  boss  or 
the  temporal  ridge,  and  making  measurements  in  inches  or  other  units 
from  these  points  on  ill-defined  lines  or  angles.  A  simpler  and  proba- 
bly more  accurate  plan  is  advocated  by  Drs.  Anderson  and  Makins,  of 


Msp 


Fig.  71. — Craniocerebral  guiding  lines  traced  upon  a  cast  of  Professor  Cunningham's  (from  a  photo- 
graph). GP,  Glabellar  point,  glabella  opposite  superior  border  of  orbit ;  IP,  inial  point,  at  external 
occipital  protuberance;  MSP,  mid-sagittal  point,  midway  between  GP  and  IP;  Ang.P,  augular  point, 
external  angular  process  opposite  upper  border  of  orbit ;  Sq.P,  squamosal  point,  intersection  of  oblique 
and  frontal  lines  at  junction  of  middle  and  lower  thirds  of  latter;  PP,  parietal  point,  termination  of 
oblique  line,  equidistant  with  FS^  from  squamosal  point;  Aur.P,  pre-auricular  point,  depression  in 
front  of  tragus,  at  the  level  of  upper  border  of  external  auditory  meatus;  FS^,  "commencement"  of 
fissure  of  Sylvius,  iive-twelfths  of  distance  from  Ang.P  to  Sq.P ;  FS=,  bifurcation  of  fissure  of  Sylvius, 
seven-twelfths  of  distance  from  Ang.P  to  Sq.P;  FS^,  termination  of  fissure  of  Sylvius,  )^  of  an  inch 
above  PP,  in  a  direction  parallel  to  frontal  line;  FR',  upper  extremity  of  fissure  of  Rolando  carried  to 
sagittal  line  in  direction  of  fissure,  %  of  an  inch  behind  mid-sagittal  point;  FR'^,  lower  extremity  of 
fissure  of  Rolando  carried  to  oblique  line  in  direction  of  fissure,  %  of  an  inch  in  front  of  squamosal 
point ;  PO.  external  parieto-occipital  fissure  carried  to  sagittal  line  in  direction  of  fissure,  seven-twelfths 
of  distance  from  MSP  to  IP. 


London,  based  upon  a  series  of  forty  observations  upon  adult  male  and 
female  heads  and  the  heads  of  children.  Tlie  system  depends  upon 
averages  and  proportions,  making  it  of  wider  application  than  the 
others.     It  has  served  the  writer  well  in  many  cases. 

First  a  line,  the  sagittal  line,  is  drawn  in  the  median  plane  from  the 
glabellar  point  to  the  external  occipital  protuberance.  The  glabellar 
point  is  determined  by  drawing  a  horizontal  line  at  the  level  of  the 
upper  border  of  the  orbital  openings,  and  marking  its  intersection  with 
the  median  plane.  It  corresponds  very  nearly  to  the  union  between 
the  nasal  and  frontal  bones.  At  exactly  one-half  the  length  of  this  line 
is  marked  a  vertical  point.  Seven-twelfths  of  the  distance  from  the 
-vertical  point  to  the  external  occipital  protuberance,  which  can  always 


168  DISEASES  OF  THE  BRAIN  PROPER. 

be  readily  located,  is  a  point  corresponding  to  the  parieto-occijiital 
fissure,  marking  the  limits  of  the  parietal  and  occipital  lobes.  From 
the  depressions  immediately  in  front  of  the  tragus  of  each  ear,  at  the 
level  of  the  upper  margin  of  the  external  auditory  meatus,  lines  called 
frontal  lines  are  drawn  to  the  vertical  point  already  mentioned.  At  the 
junction  of  the  middle  and  lower  thirds  of  the  frontal  line  lies  the  fis- 
sure of  Sylvius,  and  this  point,  corresponding  fairly  well  to  the  squamous 
suture  of  the  temporal  bone,  is  called  the  squamosal  point.  From  the 
squamosal  point  a  line,  the  oblique  line,  is  drawn  downward  and  forward 
to  the  external  angular  process  of  the  frontal  bone,  at  the  upper  orbital 
border  level,  as  in  fixing  the  glabellar  point.  Divide  this  line  into 
twelfths.  Five-twelfths  of  the  distance  from  the  angular  point  to  the 
squamosal  point  begins  the  fissure  of  Sylvius  ;  at  seven-twelfths  it  bifur- 
cates and  extends  by  its  horizontal  line  backward  under  the  oblique  line, 
and  in  its  continuation  to  a  distance  posterior  to  the  squamosal  point  equal 
to  the  distance  of  the  point  of  bifurcation  anterior  to  this  intersection 
of  oblique  and  frontal  lines.  At  the  termination  of  the  oblique  line 
the  Sylvian  fissure  turns  upward  about  J  of  an  inch  parallel  to  the 
frontal  line,  to  terminate  approximately  under  the  parietal  boss.  To 
mark  the  fissure  of  Rolando,  draw  a  line  from  the  sagittal  line  |  of 
an  inch  posterior  to  the  vertical  point  downward  and  forward,  at  an 
angle  of  about  sixty-seven  degrees,  to  terminate  f  of  an  inch  anterior 
to  the  squamosal  point  on  the  oblique  line.  The  fissure  of  Rolando 
lies  under  this  line,  but  terminates,  as  a  rule,  |  of  an  inch  above  the 
Sylvian,  though  very  rarely  opening  into  it. 

Having  thus  fixed  these  two  important  and  tolerably  uniform  fis- 
sures, the  marking  off  of  the  principal  convolutions  is  simple.  Owing 
to  the  fact  that  there  is  no  absolute  relation  between  the  cranium 
and  the  convolutions,  it  is  necessary,  when  they  are  exposed,  to  verify 
them,  if  they  are  motor  in  character,  by  the  application  of  the  faradic 
current.  This  is  done  by  means  of  an  electrode  bearing  two  probe- 
pointed  terminals  and  may  be  accomplished  through  the  unopened  dura.. 


CHAPTER  11. 

SPEECH  AND  THE  CORTEX— APHASIA. 

General  Conditions. — ^A  word  has  four  principal  cortical  qualities  : 
it  can  be  heard  and  seen,  and  it  can  be  spoken  and  written.  The  first 
two  are  afferent  qualities  of  perception.  The  second  two  are  efferent 
qualities  of  expression.  We,  therefore,  have  four  groups  of  word  mem- 
ories :  (1)  Those  of  sound,  or  auditory  word  memo7-ies  ;  (2)  those  of  sight, 
or  visual  word  memories  ;  (3)  those  of  the  motions  necessary  to  express- 
words  in  speech,  voeal  motor  word  memories,  and  (4)  probably  those  of 
the  motions  required  to  express  them  by  written  symbols,  graphic  motor 
word  memories.      For  these  four  memory  groups  we  have  four  cortical 


SPEECH  AND  THE  CORTEX—APHASIA. 


169 


memory  depots,  as  indicated  in  Fig.  72.  These  memory  word-centers  are 
brouo-ht  into  mutual  relations  by  systems  of  conne(;ting  libers  and  into 
relation  with  their  corresponding  receptive  and  emissive  peripheral  organs 
bv  aiferent  and  efferent  tracts.  We  may  indicate  these  connections  by  a 
diaorani  (Fig.  73).  Thus,  take  the  word  apple ;  when  it  is  spoken  we 
hear  it  in  the  temporal  lobe,  and  when  written  we  see  it  in  the  angular 
svre  of  the  parietal  lobe.      We  call  up  the  memory  of  muscular  move- 


Fig.  72. — Speech  areas  in  the  cortex.  A,  Auditory  word  memories  ;  B,  memories  for  motor  vocal 
speech;  C,  visual  speech  memories,  iucludiug  writteircharacters  and  lip  positions;  D,  graphic  motor 
word  memories  (after  Wyllie). 

ments  in  the  third  left  frontal  gyre  when  we  would  utter  it  vocally,  and 
those  probably  in  the  neighborhood  of  the  hand-ceuter  when  we  would 
express  it  by  writing. 

As  one  or  another  of  these  speech-centers  is  diseased  we  have  cor- 
responding varieties  of  cortical  speech 
defect,  or  aphasia.  They  are:  (1)  Au- 
ditory aphasia,  or  word-deafness;  (2) 
visual  aphasia,  or  word-blindness ;  (3) 
motor  aphasia,  or  aphemia ;  and  (4) 
graphic  motor  aphasia,  or  agraphia.  Dis- 
turbance of  the  connecting  fibers  also 
disturbs  speech,  giving  rise  to  a  number 
of  secondary  or  connecting  aphasias. 
Again,  more  than  one  center  may  be  sim- 
ultaneously affected,  causing  combined 
aphasias.  The  four  primary  word-cen- 
ters are,  to  a  varying  degree,  mutually 
dependent.  Word-blindness  is  often  at- 
tended by  agraphia,  as  the  mind  is  un- 
able to  recall  the  visual  image  of  the  word, 

which  is  to  be  copied,  as  it  were,  through  the  action  of  the  graphic 
center.  Again,  if  there  is  M'ord-deafness,  the  patient  can  not  write  to 
dictation,  though  he  may  copy  perfectly. 

Individuals  vary  greatly  in  the  local  storage  of  their  word  memories. 
As  first  emphasized  by  Charcot,  one  may  have  his  words  principally  stored 
in  the  auditory  area\auditif),  another  in  the  motor  area  (moteur),  and 


Fig.  73. — Diagram  showing  receptive 
and  emissive  speech-route,  and  the  prim- 
arv  interrelations  of  the  memory  depots  for 
speech.  A,  B,  C,  D  correspond  to  tlie 
memory  depots  similarly  indicated  in  the 
preceding  figure  (after  Wyllie). 


170  DISEASES  OF  THE  BRAIN  PROPER. 

a  third  in  the  visual  area.  If  we  learn  a  new  language  by  ear  its  mem- 
ories are  mainly  auditory,  and  if  by  the  book,  they  are  visual.  It  is 
only  when  we  have  acquired  oral  proficiency  that  our  motor  memories 
are  fully  established  and  may  finally,  perhaps,  predominate.  Probably 
only  those  who  constantly  express  themselves  in  writing  for  many  years 
so  fully  establish  the  graphic  motor  memories  that  they  become  relatively 
independent  of  the  other  word-centers.  It  follows  that  children  always 
have  auditory  word  memories  first  developed,  the  motor  or  verbal  ex- 
pression following.  The  visual  and  graphic  memories  then  in  turn  are 
acquired.  From  these  considerations  we  can  understand  how  it  is  that 
apparently  identical  lesions  may  produce  results  differing  in  degree  in 
different  cases. 

The  stability  of  word  7nemories  depends  upon  the  intensity  with 
which  they  are  imprinted  upon  the  convolutions,  either  by  some  special 
emphasis  or  by  frequent  use  and  repetition.  Thus,  words  as  well  as 
incidents  that  come  with  the  shock,  for  instance,  of  fright,  are  always 
readily  recalled.  Every  one  knows  the  value  of  repetition  in  fixing  a 
point  in  the  student's  mind.  Nouns,  being  least  frequently  used,  are  the 
most  easily  displaced,  and  proper  nouns  suffer  the  earliest  of  all.  Verbs, 
adjectives,  adverbs,  and  prepositions  follow  in  a  methodical  order,  gov- 
erned by  the  rule  of  depth  of  imprint  due  to  repetition  in  daily  use. 
This  necessarily  varies  with  the  individual.  An  oft-repeated  oath,  yes, 
and  no  are  the  most  persistent  of  all. 

It  sometimes  happens  that  the  word  or  phrase  on  the  patient's  lips,  at 
the  moment  of  the  stroke  producing  the  aphasia,  remains  his  only  vocal 
expression.  This  he  repeats  at  every  attempt  to  speak,  being,  as  it  were, 
saturated  or  intoxicated  with  it.  It  has  been  suggested  that  its  imprint 
under  the  circumstances  of  the  stroke  has  made  it  indelible.  In  writing, 
the  same  thing  is  often  indicated  by  the  repetition  of  letters  or  words. 
The  name  is  usually  signed  promptly,  if  the  patient  has  been  accustomed 
to  the  act,  which  has  in  time  become  automatic.  Sometimes  only  the 
first  few  letters  of  a  word  are  accomplished,  and  then  repeated  again  and 
again,  or  words  are  repeated.  The  tendency  to  echolalia  is  also  very 
noticeable,  the  patient  repeating  some  Avord  or  expression  he  has  himself 
uttered  or  just  heard  others  employ. 

In  many  cases  of  aphasia  the  patient  miscalls  objects  or  uses  wrong 
words,  especially  names  and  personal  pronouns.  This  is  denominated 
paraphasia,  and  is  most  marked  in  lesions  of  the  auditory  word  memory 
depot.  In  this  case  the  patient  does  not  make  persistent  attempts  to  cor- 
rect himself,  as  he  is  unable  to  recognize  his  own  mistakes.  When  the 
auditory  centers  are  not  primarily  involved  paraphasia  is  recognized  by 
the  patient,  who  constantly  manifests  his  annoyance  at  being  unable  to 
utter  the  proper  word. 

The  mental  capacity  of  aphasics  varies  greatly,  and  must  be  carefully 
estimated  in  a  given  case.  As  a  rule,  it  is  somewhat  modified,  as  is 
clearly  indicated  by  the  changed  temperament  and  disposition  practically 
always  present,  even  in  the  slightest  cases.  The  organic  mischief  pro- 
ducing the  cortical  lesion  may  induce  complete  dementia,  and  in  any 
event  the  mind  works  somewhat  clumsily.     According  to  Bastian  and 


SPEECH  A  ND  THE  COR  TEX— A  PHA  SI  A .  171 

others  the  sensory  forms  of  aphasia,  those  due  to  auditory  and  visual 
disturbance,  are  more  likely  to  present  mental  deterioration  and  to 
develop  insanity  than  the  motor  varieties.  In  such  cases  hallucinations 
of  sight  and  hearing,  due  to  irritation  of  the  cortex,  are  not  infrequent. 

Besides  the  loss  of  visual  word  memories,  the  patient  is  unlikely  to 
recall  figures,  algebraic  or  other  conventional  signs,  and  musical  notation. 
3Iincl-blinchiess,  in  which  all  objects  are  unrecognized,  their  visual  mem- 
ories being  destroyed,  is  due,  it  will  be  recalled,  to  a  bilateral  lesion. 
In  some  cases  of  auditory  aphasia  the  patient  has  shown  a  loss  of  musical 
appreciation,  a  condition  termed  amusia,  and,  as  far  as  music  is  an 
acquired  educated  faculty,  it  is  presumably  associated  with  the  left  tem- 
poral lobe.  INIost  motor  aphasics  whistle  or  hum  tunes  with  more  or  less 
precision,  and  cases  are  of  record  where  motor  speech  was  lost,  but  the 
patient  could  sing  the  words  of  a  song  correctly.  One  case  recently  seen 
replied  "  God  damn  "  to  every  question,  but  got  out  most  of  the  words 
of  "Annie  Rooney"  with  distinctness  when  he  attempted  to  sing. 

Secondary  means  of  expression,  such  as  pantomime,  facial  expression, 
and  gestures,  are  usually  retained,  but  in  rare  cases  the  patient  neither 
correctly  produces  nor  understands  them.  This  may  go  to  the  extent 
of  nodding  the  head  when  negation  is  intended.  The  loss  of  gesture  and 
mimicry  is  called  amimia  ;  the  misuse  of  these  is  paramimia.  Emotional 
facial  expression  is  generally  retained,  so  that  when  the  mind  is  not 
too  much  impaired  the  feelings  of  the  patient  are  vividly  portrayed  in 
his  countenance.  There  is  some  reason  to  locate  these  expressional 
centers  in  the  basal  ganglia,  especially  in  the  optic  thalamus. 

The  motor  cortex  subserving  speech  is  all  within  the  domain  of 
the  middle  cerebral  artery,  and  aphasia  is  most  frequently  due  to 
diseases  of  the  branches  or  the  trunk  of  this  vessel.  Trauma,  men- 
ingitic  disease,  and  new  growths  may  also  cause  it.  The  most  common 
simple  variety  of  aphasia  is  the  motor  form,  next  the  auditory,  and 
then  the  visual.  Distinct  cases  of  graphic  motor  aphasia  are  extretuely 
rare,  but  a  convincing  instance  has  been  recorded.  A  combination 
-of  motor  aphasia  with  the  auditory  and  visual  varieties  is  that  ordi- 
narily encountered.  In  this  connection  the  various  memory  areas  may 
be  affected  in  different  degree.  No  two  cases  in  any  one  man's  ex- 
perience are  exactly  alike.  Variations  due  to  improvement  or  failure 
in  the  various  speech  qualities  in  any  given  case  furnish  constant 
study.  It  is  important  to  know  the  initial  conditions,  when  usually 
the  picture  is  complete,  in  order  to  estimate  the  extent  of  the  lesion. 
After  a  few  weeks  or  months,  through  education  of  the  opposite  cortex 
and  partial  local  recovery,  the  clinical  picture  may  be  entirely  altered 
and  quite  deceptive. 

Before  taking  up  the  various  forms  of  aphasia  the  reader  is  referred 
to  the  methods  of  examination  in  such  cases  described  in  Part  I,  page 
23.  It  may  be  well  to  call  attention  to  the  fact  that  the  blind  read 
type  with  their  fingers,  and  that  the  deaf,  by  lip  readiug,  cultivate 
special  verbal  memories,  which  must  be  specially  localized  in  the  cortex. 
We  must  also  bear  in  mind  that  the  word  and  the  object  are  not  the 
same,  but  that  one  is  the  symbol,  sign,  or  name  of  the  other.      The  word- 


172  DISEASES  OF  THE  BRAIN  PROPER. 

percept  is,  therefore,  distinct  from  the  object-percept,  which  is  a  part  of 
the  higher  intelligence.  It  follows  that  the  aphasic  can  mentally  recall 
the  object,  as  a  chair,  though  he  can  not  name  it.  The  object-percept 
may  also  be  called  up  by  various  routes  besides  those  of  hearing  and  see- 
ing. By  smell,  or  touch,  or  taste  alone  we  can  recognize  familiar  quan- 
tities that  have  corresponding  qualities,  and  at  once  the  word  or  name 
springs  to  the  lips.  The  object-percept  is,  therefore,  made  up  of  and 
embraces  all  the  attributes  of  the  given  object  with  which  the  individual 
is  definitely  acquainted. 

Auditory  Aphasia. — The  lesion  is  in  the  left  temporal  lobe.  The 
most  striking  condition  is  the  word-deafness.  The  patient  gets  only  a 
partial  suggestion  of  what  is  spoken  to  him,  or  fails  completely.  When 
the  intellect  is  fairly  .clear  he  is  likely  to  make  good  guesses  from  the 
circumstances  of  the  interview,  the  examiner's  gestures,  intonation,  ex- 
pression, or  the  motion  of  his  lips.  These  sources  of  suggestion  must 
be  guarded  in  making  tests.  Usually,  the  visual  speech-center,  from  its 
near  location,  suffers  with  the  auditory,  so  that  alexia  is  added,  but  if  it 
escapes,  the  patient  may  read  understandingly. 

As  most  people  are  strongly  auditif,  the  destruction  of  their  auditory 
word  memories  notably  impairs  the  emission  of  vocalized  words.  This 
manifests  itself  in  paraphasia,  and  the  speech  may  be  reduced  to  a  jargon 
or  gibberish,  which  the  patient  expresses  in  a  well-modulated  way,  and 
with  an  intelligent  appearance.  He  does  not  recognize  his  own  mistakes 
because  of  the  word-deafness.  He  is  likely  to  coin  words  and  to  repeat 
syllable  sounds.  Frequently  he  starts  a  word  properly  and  then  muti- 
lates it.  In  trying  to  describe  his  feelings,  such  a  patient  said,  with 
gestures  to  his  head  and  abdomen,  "  I  have  a  sulitar  pretty  well  dear 
swell  manoeuver,  and  there  are  fullis  things  that  hang  solidar.  There  is 
a  clean,  fleshurable,  pleasurable,  fair,  unsurizable,  and  any  surizable  way 
for  a  good  deal  insurations  that  is  rotality  all  the  time."  He  was 
annoyed  that  others  could  not  understand  him,  and  that  he  could  not 
fully  understand  others.  Very  rarely  would  he  attempt  to  correct  a 
word.  The  writing  of  such  a  patient  shows  the  same  thing  as  his  vocal 
utterances,  both  indicating  the  loss  of  the  auditory  speech  memories  upon 
which  the  majority  of  mankind  are  mainly  dependent.  He,  therefore, 
uses  wrong  words,  repeats  words  or  letters,  or  his  attempts  lose  all 
semblance  to  written  speech.  The  ability  to  repeat  words  from  dicta- 
tion, or  to  echo  sounds,  may  be  destroyed,  and  is  always  greatly  im- 
paired. Copying  written  or  printed  characters  is  not  affected.  Amusia 
may  be  present. 

Motor  Aphasia,  or  Aphemia. — The  lesion  is  in  the  foot  of  the 
third  left  frontal  convolution,  Ijut  usually  extends  to  the  foot  of  the  as- 
cending frontal,  giving  rise  at  the  same  time  to  motor  difficulties  in  the 
lips  and  tongue.  The  characteristic  condition  in  marked  cases  at  first 
is  the  inability  to  produce  articulate  speech.  Remnants  like  yes  and  no, 
or  expletives,  or  an  occasional  habitual  word  may  be  retained,  repre- 
sented, as  it  is  supposed,  through  the  overflow  into  the  right  half-brain 
which  occurs  in  the  process  of  cortical  education.  As  the  right  side  is 
further  educated,  or  if  partial  recovery  in  the  left  side  ensues,  the  vo- 


SPEECH  AND  THE  CORTEX— APHASIA. 


173 


cabulary  increases.  In  the  young  the  education  of  the  right  convolutions 
goes  on  with  considerable  rapidity  if  the  mental  impairment  is  slight. 
In  recovering  and  in  partial  cases  attempts  at  articulate  vocal  expression 
partially  fail,  from  the  loss  of  the  memory  of  verbal  motor  combinations. 
In  severe  cases  the  condition  is  absolute.  Motor  aphasics  sometimes  mis- 
use nouns  (paraphasia),  and  they  at  once  recognize  their  errors.  They 
frequently  paraphrase  to  get  around  their  naming  defect,  as,  for  in- 
stance, "  Give  me  some  of  that  stuif  for  the  bread,"  meaning  butter. 
Wyllie  also  calls  attention  to  the  infantile  characters  of  the  speech  in  im- 
proving motor  aphasia,  such  as  lisping,  lalling,  and  the  cutting  off  of 
terminals  and  initial  syllables.  They  can  not  repeat  dictation  any  better 
than  they  can  speak  spontaneously.  As  a  rule,  agraphia  is  present  and 
proportionate  to  the  motor  aphasia.  For  this  a  number  of  reasons  are 
assigned.     Usually  there  is   right   hemiplegia   and  the   right  hand   is 


(A-M^Z^l..-t^^ 


Fig.  74. — Handwriting  in  a  case  of  motor  aphasia.     Patient's  attempt  to  write  his  own  name — Geo.  W. 
Whitehall :    A,  spontaneously  ;   B,  after  dictation. 


powerless.  When  the  hand  is  not  disabled  the  agraphia  persists  none 
the  less.  It  will  be  recalled  that  tlie  graphic  motor  word  memories  are 
last  acquired,  the  least  deeply  imprinted,  and  probably  very  easily  disar- 
ranged. They  are,  no  doubt,  closely  associated  with  the  motor  vocal 
memories,  not  only  by  nearness  of  location,  but  in  function.  As  one 
learns  to  write,  and  even  after  much  usage  of  the  pen,  he  unconsciously 
inwardly  pronounces  first  the  letters  singly  and  later  the  syllable 
sounds  as  he  executes  the  written  characters.  A  few  rare  cases  of  motor 
aphasia  have  retained  fairly  good  use  of  written  speech.  These  have  pre- 
sented subcortical  lesions  in  some  instances  and  cortical  lesions  in  others. 
It  may  be  that  the  individuals  possessing  deeply  imprinted  auditory,  vis- 
ual, and  graphic-motor  word  memories  would  be  less  aifected  than  the 
usual  auditif-moteur  class.  In  attempts  at  writing,  motor  aphasics  fre- 
quently repeat  a  word  or  letter,  or  write  only  the  few  words  of  which  they 
are  vocally  capable.    Their  names  are  usually  signed  with  readiness  if  they 


1  (  4  DISEASES  OF  THE  BRAIN  PROPER. 

can  guide  the  hand.  The  motor  aphasic  who  is  able  to  use  his  right 
hand  can  copy  readily  and  accurately,  though  he  usually  is  unable  to  read. 
Even  with  the  left  hand  they  can  copy  as  well  as  another.  From  dicta- 
tion their  efforts  are  no  better  than  in  spontaneous  attempts.  The  motor 
aphasic  understands  all  he  hears  and  obeys  commands.  There  is  no 
word-deafness. 

Reading  is  notably  impaired  and  in  the  same  degree  as  w^riting.  The 
association  of  visual  speech  with  motor  speech  is  a  close  one.  All  in 
learning  to  read  pronounce  as  they  go  along,  and  even  in  after  life,  when 
one  is  reading  carefully,  the  tongue  will  be  found  slightly  moving  in  the 
mouth  in  the  same  manner  that  the  words  would  require  were  they  pro- 
nounced. Yet  many  of  these  patients  will  intently  scan  the  papers  for 
hours  or  apparently  read  and  reread  the  same  books  and  insist  that  thay 
understand  what  they  read.  They  almost  invariably  recognize  their 
own  names  and  in  some  cases  seem  to  get  the  "  drift "  of  what  thev  read. 

Motor  aphasics  showing  a  high  degree  of  verbal  difficulty  are  the 
ones  in  whom  amimia  and  paramimia  are  usually  observed.  Occasion- 
ally they  can  not  voluntarily  protrude  the  tongue. 


Fig.  75. — A  lesiou  (X)  divides  the  optic  radiations  within  the  occipital  lobe,  producing  hemiauopsia  and 
wofd-bliuduess  at  ooce  (Dejeriue). 

Visual  Aphasia. — A  lesion  destroying  the  angular  g}a'e  on  the  left 

side  produces  the  peculiar  defect  of  visual  aphasia,  or  word-blindness. 
If  this  lesion  extends  deeply  enough  to  involve  the  optic  radiations 
streaming  from  the  Ijasal  ganglia  to  the  occipital  cortex,  hemianopsia  is 
added.  A  lesion  in  the  optic  radiation  within  the  white  matter  of  the 
occipital  lobe  may  involve  the  connecting  tracts  between  the  half-vision 
centers  in  the  apex  and  the  higher  visual  centers  in  the  angular  gyre, 
producing  both  hemianopsia  and  word-blindne.ss.  It  thus  appears  that 
word-blindness  is  due  to  disturbance  of  the  angular  gyre  alone,  and  that 
associated  hemianopsia  is  present  only  when  the  lesion  implicates  the 
optic  2'adiation  (see  Fig.  75). 

The  visual  aphasic  can  see  perfectly  anything  put  before  him,  but 
written  symbols,  figures,  and  other  conventional  signs  have  entirely  lo.st 
their  significance.  That  he  sees  them  clearly  is  shown  by  the  fact  that 
he  can  copy  or  draw  them  Avith  as  much  precision  as  ever.  Spontaneous 
Avriting,  however,  is  lacking.  Not  being  able  to  call  up  the  vi.sual 
images  of  written  speech,  he  is  unable  to  exteriorize  them  through  the 


SPEECH  A  NT)  THE  COB  TEX- A  PHA  SI  A .  175 

motor  writing  apparatus,  excepting  in  the  case  of  some  automatic  com- 
binations, such  as  his  signature.  For  similar  reasons  he  can  not  write 
from  dictation.  The  hemianopsic  cases,  however,  write  spontaneously  and 
from  dictation  with  ordinary  facility,  as  in  these  cases  the  visual  word 
memories  are  not  necessarily  destroyed,  but  only  cut  off  from  the  lower 
half-vision  cortex  in  the  occipital  apex.  They  are  unable,  however,  to 
read  what  they  have  written.  Spoken  language  is  both  understood  and 
expressed  with  complete  readiness.  When  familiar  objects  are  not  rec- 
ognized, mind-blindness  is  present  and  the  lesion  is  probably  bilateral. 
It  appears  that  ordinary  visual  sensations,  as  sensation  in  general,  are 
symmetrically  represented.  The  educated  faculty  of  visual  word  mem- 
ories is  represented  in  the  left  angular  gyre  alone. 

Graphic-motor  Aphasia. — Regarding  this  variety  of  aphasia  there 
is  mucli  dispute  and  uncertainty.  According  to  some,  Wernicke  in 
particular,  the  act  of  writing  is  but  the  act  of  tracing  the  visual  word 
memories.  He  points  out  that  this  can  be  done  w^ith  the  left  hand,  the 
elbow,  the  foot,  or  even  with  a  pencil  held  between  the  teeth.  Exner 
maintains  that  there  is  a  graphic-motor  center  in  the  foot  of  the  second 
frontal  convolution  adjoining  the  centers  for  the  hand,  but  this  is 
not  sufficiently  verified.  The  case  reported  by  Gordinier,  ^  however, 
is  very  convincing.  In  this  instance  the  circumscribed  lesion,  a 
small  new  growth,  was  located  in  the  foot  of  the  left  second  frontal 
convolution.  The  facility  with  which  the  right  is  used  as  com- 
pared with  the  left  hand,  or  the  other  portions  of  the  body,  indicates 
that  it  has  attained  a  proficiency  quite  its  own,  which  must  be  resi- 
dent in  its  principal  cortical  representation.  Some  persons  write  with 
small  finger  movements,  others  with  a  wide,  full  arm-sweep,  the  pen 
being  simply  grasped  with  the  hand,  which  is  largely  guided  from  the 
shoulder.  An  ambidexter  uses  either  hand.  Their  cortical  writing 
apparatus  must  vary  correspondingly.  In  persons  deprived  of  both 
hands,  who  write  with  the  foot,  quite  another  cortical  area  must  be 
educated  for  the  purpose.  It  seems  probable  that  in  every  case  this 
education  would  fall  upon  the  corresponding  sensorimotor  cortex,  which 
develops  specially  intimate  relations  with  the  area  of  visual  speech. 
Even  this  relation  is  not  absolutely  required,  as  the  blind  accurately 
reproduce  the  letter  forms  they  have  learned  by  the  sense  of  touch. 

It  seems  unnecessary  to  presume  the  existence  of  a  higher  graphic- 
motor  center.  A  lesion  which  upsets  the  motor  memories  of  writing 
would,  therefore,  probably  paralyze  the  muscle  groups  used  in  the  act, 
and  it  would  be  impossible  to  decide  whether  the  difficulty  arose  from 
the  obliteration  of  specialized  motor  memories  or  those  proper  to  the 
member.  In  such  cases  the  left  hand  writes  as  readily  as  ever  if  the 
visual  word  memories  are  not  impaired. 

It  will  be  recalled  that  agraphia  is  common  in  motor  and  usual  in 
auditory  aphasia.  In  auditory  aphasia  we  more  commonly  have  para- 
graphia, unless  the  lesion  also  involves  the  visual  speech-cortex.  The 
usual  proportionate  relation  of  agraphia  to  motor  aphasia  early  sug- 

1  "Am.  Jour.  Med.  Sci.,"  May,  1899. 


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176 


SPEECH  AND  THE  CORTEX— APHASIA.  Ill 

gested  to  Broca  and  Trousseau  that  the  motor  speech-center  must 
control  this  form  of  emissive  ex})ression  as  ^vell  as  that  by  tlie  oral 
apparatus.      There  is  a  general  inclination  to  return  to  this  view. 

Conduction  Aphasias. — The  aphasias  thus  far  considered  are  due  to 
lesions  of  single  memory  depots.  There  are  others  due  to  lesions  of  the 
conducting  tracts  that  bring  these  depots  into  mutual  and  coordinate 
relations.  The  most  important  is  the  one  produced  by  breaking  the 
path  between  the  auditory  and  motor  word-centers.  This  is  usually  due 
to  a  lesion  of  or  in  the  neighborhood  of  the  island  of  Reil.  It  was 
first  described  by  Wernicke  and  is  sometimes  called  Wernicke's  con- 
duction aphasia.  These  patients  present  no  particular  auditory  or  articu- 
lative  difficulty,  but,  owing  to  the  loss  of  correlation  between  auditory 
and  motor  memories,  they  lose  selective  ability  when  they  try  to  express 
themselves,  and  a  most  marked  paraphasia  and  paragraphia  result. 
They  are  obedient  to  direction,  but  can  not  repeat  dictation  orally  or  in 
writing,  though  they  copy  with  perfect  precision.  Neither  can  they 
read  or  pronounce  aloud,  though  they  seem  to  read  understandingly. 
There  is  very  little  attempt  to  correct  errors  of  spoken  or  written 
speech.  The  writer  has  seen  such  a  case,  due  to  traumatic  hemorrhage, 
which  was  relieved  by  operation,  the  clot  being  found  under  the  oper- 
culum on  the  surface  of  the  insular  convolutions,  where  it  had  been 
located  from  the  symptoms.  The  recovered  patient  now  states  that 
there  was  considerable  mental  confusion  during  the  aphasia,  to  which 
the  verbal  disturbance  no  doubt  would  conduce. 

Wernicke,  Lichtheim,  Wyllie,  and  others  describe  four  other  varie- 
ties of  conduction  aphasia  depending  upon  the  location  of  the  lesion  in 
relation  to  the  conducting  tracts  to  and  from  the  auditory  and  motor 
word  memories.  Some  quoted  cases  also  are  given  in  their  support. 
Anatomical  findings  as  yet  are  scarcely  adequate  to  firmly  establish 
these  varieties,  which,  however,  serve  to  complete  the  pathological  study 
of  the  subject.      By  their  aid  some  rare  instances  can  be  deciphered. 

Combined  Aphasias. — It  has  been  pointed  out  that  all  the  word- 
memory  depots  are  in  the  arterial  territory  of  the  middle  cerebral. 
Consequently  from  this  source,  as  well  as  by  trauma,  meningitis,  or 
cerebritis,  they  may  all  be  thrown  out  at  once.  Simultaneous  injury  to 
the  auditory  and  visual  word  memories  is  comparatively  frequent,  and 
it  has  been  seen  that  graphic-motor  memories  usually  disappear  with 
vocal  motor  memories — a  comljination  due  not  only  to  association  in 
function,  but  to  proximity  of  centers,  if  a  special  one  for  writing  is 
admitted.  The  loss  of  auditory  and  motor  memories  practically  entails 
a  loss  of  all  speech  attributes,  as  the  visual  and  graphic-motor  centers 
are  so  thoroughly  dependent  upon  them.  Again,  the  centers  may  be 
unequally  affected,  so  that  sensory  disturbance  preponderates  over  motor, 
or  the  contrary.  The  type  cases  indicated  in  the  foregoing  pages  are 
indeed  rare,  but  only  by  their  full  comprehension  can  we  unravel  the 
combined  forms. 

The  mental  disturbance  is  usually  proportionate  to  the  speech  defect, 
^nd  in  total  aphasia  is  very  marked. 

Reeducation  of  Aphasics. — One  of  the  most  important  questions  in 
12 


178  DISEASES  OF  THE  BRAIN  PROPER. 

a  given  case  of  aphasia  regards  recovery  from  the  speech  defect.  Pure 
motor  aphasia  is  perhaps  the  most  hopeful  variety  in  this  respect,  as 
verbal  motor  memories  are  the  most  easily  built  up.  Reading  usually 
follows  much  more  slowly  and  writing  is  even  more  tardy.  The  forms 
of  aphasia  connected  with  the  loss  of  sensory  word  memories  are  the 
most  persistent.  As  often  mentioned,  a  majority  of  persons  are  auditif, 
and  all  are  necessarily  so  in  childhood,  though  the  child  intently  watches 
the  lips  of  those  teaching  it  to  speak  and  probably  acquires  visual 
memories  in  association  with  the  auditory  impressions.  In  the  sensory 
aphasias  the  mental  disturbance  is  usually  greatest.  The  loss  of  these 
earliest  and  usually  most  deeply  graven  memories,  which  become  domi- 
nant in  the  speech  mechanism,  is  the  most  difficult  to  overcome. 

The  first  step  is  to  determine  by  which  route  the  intelligence  may 
best  be  reached.  Even  when  both  auditory  and  visual  memories  are 
gone  some  patients  can  use  the  sense  of  touch  to  good  advantage,  and 
it  will  often  be  found  an  aid  to  put  familiar  objects  into  their  hands 
when  encouraging  them  to  name  them.  If  they  are  capable  of  giving 
attention,  much  may  be  expected.  Simple  sounds,  such  as  a  child 
first  utters,  like  ba,  pa,  ma,  may  be  indicated  to  them  and  repeated  by 
the  voice  and  in  writing,  by  the  position  of  the  lips,  mouth,  and  tongue 
of  the  instructor,  or  by  taking  the  patient's  hand  and  tracing  the  letters 
either  in  air  or  on  a  blackboard.  If  some  object  can  be  used, — say,  a 
knife  or  pen, — it  should  be  kept  before  the  patient  and  placed  in  his  hand 
when  he  attempts  to  name  it.  When  simple  sounds  are  mastered  they 
can  then  be  grouped  into  words,  and  the  words  associated  with  objects 
or  actions,  and  so  a  vocabulary  built  up,  which  must  be  frequently  and 
repeatedly  and  patiently  rehearsed.  By  unremitting,  intelligent  eifort, 
some  emissive  speech  may  be  taught  even  the  most  hopeless  cases.  It 
adds  greatly  to  their  comfort  and  makes  their  care  less  burdensome. 


CEREBRAL   WHITE  3IATTER,  BASAL  GANGLIA,  CEREBELLUM.    179 


CHAPTER  III. 

THE  CEREBRAL  WHITE  MATTER,  BASAL  GANGLIA, 
AND  CEREBELLUM. 

Descending  from  the  cortex  in  converging  lines  we  have  the  corona 
radiata,  the  fibers  of  which  bring  the  brain-mantle  into  relation  with  the 
lower  brain  parts  and  the  spinal  cord.  Through  the  corpus  callosum  the 
homologous  cortical  elements  on  the  two  sides  of  the  brain  are  brought 
into  harmonious  relation.  The  descending  tracts  reaching  the  basal 
ganglia  are  condensed  into  the  internal  capsule,  in  which  the  cortical 
motor  fields  are  represented  from  head  to  foot,  in  an  order  from  before 
backward,  as  indicated  in  figure  76. 


EYES  OPENED 
EYES  TURNED 
MOUTH    OPENED 

HEAD  TURNED 

TONGUE 

MOUTH    RETRACTED 

SHOULDER 

ELBOW 

WRIST 

FINGERS 

THUMB 

TRUNK 

HIP 

ANKLE. 

KNEE 

HALLUX 

roEs 


Fig.  76. — Arrangement  of  motor  paths  in  the  internal  capsule  (after  Ferrier). 

The  internal  capsule  lies  between  the  lenticular  part  of  the  striate 
body  externally  and  the  caudate  nucleus  and  the  optic  thalamus  on  its 
median  aspect,  but  is  not  dependent  upon  them.  Its  anterior  portion, 
or  limb,  is  supposed  to  contain  psychic  paths  to  the  frontal  lobes. 
Lesions  of  this  part  of  the  internal  capsule  produce  no  distinctive 
symptoms.  The  motor  routes  lower  down  are  continued  in  the  under 
portion  of  the  crura  and  so  on  through  the  pons  into  the  medulla  and 
cord.     The  motor  paths  and  their  relations  are  indicated  in  figure  77, 


180 


DISEASES  OF  THE  BRAIN  PROPER. 


which  shows  that  the  face  mechanism  is  inferiorly  situated  iu  the  cortex, 
anteriorly  in  the  capsule,  and  internally  in  the  crus. 

The  sensory  paths,  situated  in  the  posterior  columns  of  the  cord,  pass 
upward  into  the  posterior  third  of  the  hinder  limb  of  the  internal  cap- 
sule. They  reach  the  cortex  of  both  hemispheres,  according  to  Brissaud 
and  others,  directly  on  the  same  side  and  indirectly  on  the  opposite  side, 
by  sending  off  a  branching  path  through  the  corpus  callosum,  as  shown 
in  figure  78.  Bilateral  sensory  representation  is  thus  provided  for. 
Doubtless  motion  is  originally  equally  symmetrical  in  its  cortical  repre- 
sentation, the  apparent  functional  diiference  arising  from  the  specializing 
of  unilateral  motility  in  the  opposite  or  most  intimately  related  cortex, 
by  practice,  habit,  and  education. 

From  these  diagrams  we  can  understand  that  lesions  in  the  cerebral 


Fig.  77. — Diagram  to  show  the  relative  position  of  the  several  motor  tracts  iu  their  course  from  the 
cortex  to  the  crus.  The  section  through  the  convolutions  is  vertical ;  that  through  the  interual  capsule, 
1,  C,  horizontal ;  that  through  the  crus  is  again  vertical ;  CN,  caudate  nucleus  ;  O,  TH,  optic  thalamus ; 
L-  and  L^,  the  middle  and  outer  parts  of  the  lenticular  nucleus  ;  /,  a,  /,  face,  arm,  and  leg  fibers.  The 
vfords  iu  italics  indicate  the  correspondiDg  cortical  centers  (after  Gowers). 


white  matter  must  be  clo.se  to  the  cortex  or  in  the  internal  capsule  to 
produce  permanent  and  definite  sensory  symptoms,  as  otherwise  placed 
they  do  not  intercept  the  pathways  to  both  hemispheres.  The  symp- 
toms in  subcortical  lesions  correspond  to  the  function  of  the  related 
cortex,  and  in  capsular  lesions  to  the  function  of  the  particular  tracts 
involved.  The  radiations  to  and  from  the  cortex  in  the  area  of  latent 
lesions  may  be,  and  often  are,  involved  without  giving  rise  to  any 
symptoms. 

The  corpus  callosum  may  be  diseased  to  almost  any  extent  without 
presenting  any  peculiar  symptoms.  Bristowe,  Sharkey,  and  Schutfer^ 
contend  that  tumors  of  the  corpus  callosum  are  likely  to  produce 
hebetude,  apathy,  and  prolonged  placid  coma.     If  its  function  is  but 

-  "Rev.  Speriment. , "  vol.  xxviii,  p.  2. 


CEREBRAL   WHITE  MATTER,  BASAL  GANGLIA,  CEREBELLUM.     181 

to  furnisli  correlating  tracts  between  the  two  sides  of  the  brain,  their 
destruction  would  not  materially  interfere,  perhaps,  with  the  independent 
action  of  the  lialf-l)rain.  Putnam  and  Williams  ^  note  that  in  tumors 
of  the  corpus  callosum  mental  changes  are  the  only  common  symptoms, 
these  consist  in  changes  of  character,  impairment  of  memory  and  men- 
tality, stupor,  hallucinations,  irritability  and  attacks  of  excitement. 
Epileptoid  attacks,  hemiplegia  passing  into  diplegia  most  pronounced  in 
the  legs,  and  a  peculiar  ataxia,  a  sort  of  lack  of  balance,  and  a  poverty 
of  movement  have  been  variously  recorded. 

Lesions  involving  the  optic  radiations  in  the  occipital  lobes  produce 
hemianopsia,  and  when,  on  the  left  side  they  cut  the  radiations  from  the 
occipital  apex  to  the  angular  gyre,  word-blindness  ensues,  as  described 
on  page  174.  Lesions  beneath  the  auditory  word-centers  likewise  pro- 
duce word-deafness. 

The  corpora  striata  can  be  completely  destroyed  on  both  sides  without 
giving  rise  to  motor  or  sensory  disturbance  if  the  internal  capsule  escapes. 
Their  function  is  still  a  matter  of  speculation.  Ijesions  aifecting  them, 
however,   almost   invariably   implicate   the    capsular   tracts.      In  this 


..NC 


SG(B) 
SG(G) 


Fig.  78.— Schematic  vertical  transverse  section  of  the  hemispheres  passing  through  the  internal 
capsule  and  representing  the  sensorv  pathways.  G,  Left  hemisphere;  D,  right  hemisphere;  cc,  corpus 
callosum;  ci,  internal  capsule;  SG,  sensory  i)athway  from  left  side  of  cord;  SD,  sensory  pathway  from 
right  side  of  cord.  Both  sides  are  broiighl"  iiitci  intimate  relation  through  the  corpus  callosum,  and  the 
sensory  representation  is  uniformly  bilateral  (alter  Brissaud). 


locality  we  encounter  the  hemorrhagic  lesion  that  is  preeminently  causa- 
tive of  apoplectic  hemiplegia.  Whether  or  not  posthemiplegic  choreic 
movements  and  athetosis  are  due  to  disease  of  the  basal  ganglia  can  not 
be  definitely  stated,  but  lesions  in  this  locality  are  frequently  attended 
by  such  motor  disorders. 

The  optic  thalami,  when  diseased,  give  rise  to  no  definite  symptoms 
1  "Jour.  Nerv.  and  Ment.  Dis.,"  Dec,  1901. 


182  DISEASES  OF  THE  BRAIN  PROPER. 

if  the  lesions  are  confined  to  their  anterior  portions  and  do  not  invade 
the  capsule.  When  the  hinder  portion  of  the  optic  thalamus  is  involved 
we  are  likely  to  have  either  a  crossed  blindness  or  a  double  hemianopsia, 
probably  from  simultaneous  injury  to  the  optic  tract.  Bechterew  claims, 
with  much  probability,  that  facial  emotional  expressions  are  controlled 
by  the  thalamus  in  some  manner.  Brissaud,  in  cases  of  postparalytic 
spasmodic  crying  and  laughing,  locates  the  lesion  near  the  knee  of 
the  internal  capsule.  The  loss  of  facial  emotional  expression  at  least 
points  to  the  internal  capsule  and  the  optic  thalamus  rather  than  to  the 
cortex. 

The  corpora  quadrigemina  are  seldom  singled  out  by  brain-lesions. 
When  involved,  adjoining  structures  almost  invariably  suffer,  so  that 
the  resulting  symptoms  are  difficult  to  analyze.  The  anterior  pair  are 
associated  with  vision,  and  apparently  with  some  ocular  movements. 
The  pupillaiy  reflex  and  movements  of  the  eyeballs  have  been  bilaterally 
impaired  in  some  cases  when  they  were  diseased,  and  nystagmus,  en- 
feebled vision,  and  blindness  have  been  noted.  ^  The  posterior  pair  are 
thought  to  be  related  to  hearing  and  equilibration.  When  they  are 
diseased,  the  adjoining  portion  of  the  middle  cerebellar  lobe  is  usually 
involved,  and  probably  gives  rise  to  the  symptoms  mentioned.  Ray- 
mond 2  contends  that  circumscribed  lesions  limited  to  the  region  of  the 
corpora  quadrigemina  are  prone  to  present  (a)  diminution  of  visual 
acuity,  (6)  palsies  of  associated  ocular  movements,  (c)  pupillary  anoma- 
lies, (d)  paresthesias  on  one  or  both  sides  of  the  body,  (e)  ataxic  dis- 
orders of  movement  in  the  limbs,  (/)  athetoid  and  choreiform  move- 
ments, (g)  contralateral  diminution  of  hearing,  (A)  rarely  disturbance 
of  mastication  by  implication  of  the  motor  root  of  the  fifth  cranial  nerve. 

The  crura  cerebri  contain  the  motor  tracts  on  their  under  portions 
and  the  sensory  tracts  above.  Crural  lesions,  therefore,  produce  hemi- 
plegia of  the  face  and  limbs  on  the  opposite  side,  marked  by  hemi- 
anesthesia if  the  sensory  paths  are  at  the  same  time  involved.  The 
proximity  of  the  third  nerve,  as  it  issues  from  the  inner  border  of  the 
cms,  lays  it  liable  to  damage  at  the  same  time,  and  then  we  also  have 
an  ophthalmoplegia.  This  affects  the  eye  on  the  same  side  as  the  lesion 
and  opposite  to  the  paralyzed  limbs, — the  Weber  syndrome.  When  the 
lesion  is  deep,  it  gives  rise  to  nuclear  disturbance,  as  described  under 
Diseases  of  the  Cranial  Nerves. 

The  pons  Varolii,  when  diseased,  often  presents  characteristic  symp- 
tom groups  that  make  the  localizing  diagnosis  comparatively  easy.  It 
will  be  recalled  that  besides  giving  passage  to  the  pyramidal  tracts, 
which  course  downward  from  the  crura  to  the  medulla  oblongata,  it  is 
traversed  by  the  root-fibers  of  the  fifth,  sixth,  and  seventh  pairs  of 
cranial  nerves  from  their  nuclear  to  their  appai'ent  origins.  The  course 
of  the  facial  fibers  and  their  decussation  in  the  substance  of  the  pons 
opposite  the  apparent  origin  of  the  fifth  pair  are  described  on  page  117 
and  shown  in  figure  45.  If  a  lesion  falls  upon  the  facial  fibers  before 
they  decussate,  and  at  the  same  time  involve  the  pyramidal  tract,  which 

^  Biancone,  "Rev.  Speriment.,"  Dec,  1899. 
2  "Lecons,"  Paris,  1901. 


CEREBRAL   Wlini:  MATTER,  BASAL  GANGLIA,  CEREBELLUM.     183 

decussates  lower  down  in  the  iiiediilla,  a  paralysis  of  motion  for  the  face 
and  limbs  on  the  side  opposite  the  lesion  ensues.  If  the  lesion  occurs 
below  the  facial  crossing;, — namely,  in  the  low^er  third  of  the  pons, — it 
will  aifect  the  face  on  the  same  side  and  the  limbs  on  the  opposite  side, 
producing  a  crossed  or  alternating  paralysis.  Whether  or  not  sensory 
symptoms  are  added  depends  upon  the  implication  of  the  tegmental  fibers, 
which  lie  above  or  behind  the  motor  tracts.  When  this  is  the  case  the 
motor  nucleus  of  the  sixth  nerve  or  its  root-fibers  is  usually  implicated 
at  the  same  time,  so  that  conjugate  deviation  of  the  eyes  tow^ard  the 
side  of  the  lesion  and  away  from  the  paralyzed  limbs  is  impossible.  In 
destructive  cerebral  lesions  higher  up,  it  will  be  recalled,  the  ocular 
deviation  is  toward  the  lesion  and  away  from  the  paralyzed  limits. 
Pontine  disease  may  involve  the  motor .  speech-paths,  which  lie  dorsad 
in  the  median  portions  of  the  pyramidal  tracts,  and  give  rise  to  articu- 
lative  disturbance  very  like  motor  aphasia.  Extension  of  the  lesion 
dorsad  and  cephalad  may  involve  the  oculomotor  centers. 

The  motor  and  sensory  portions  of  the  fifth  cranial  nerve-root  may 
be  involved  separately  or  together,  and  trismus  may  be  induced  by  irrita- 
tion of  the  motor  nuclei.  A  lesion  which  cuts  the  sensory  root-fibers  of 
the  fifth  indnces  anesthesia  in  the  face  on  the  same  side  and  crossed 
paralysis  in  the  limbs  through  injury  to  the  pyramidal  tract.  Rigidity, 
spasm,  and  choreoid  movements  in  the  limbs  are  sometimes  encountered, 
and  convulsions,  in  acute  disease,  are  common.  If  the  middle  cerebellar 
peduncle  is  affected,  vertigo,  vomiting,  and  tinnitus  are  usually  present, 
and  deafness  on  the  same  side  may  ensue.  Irritative  lesions  of  this 
peduncle  produce  forced  gyratory  movements  or  forced  one-sided  posi- 
tions in  lying,  which  may  be  accompanied  by  corresponding  positions  of 
the  head  and  eyes  in  the  direction  to  which  the  turn  is  made.  This 
may  or  may  not  correspond  to  the  side  of  the  lesion. 

The  medulla  oblongata,  owing  to  its  small  size  and  the  vital  impor- 
tance of  its  nuclei,  is  most  rarely  invaded  by  acute  disease  without  an 
immediately  fatal  termination.  Disease  of  the  olivary  body  may  cut 
off*  the  hypoglossal  nerve  and  at  the  same  time  cause  a  crossed  paraly- 
sis— the  tongue  on  the  same  side  and  the  limbs  on  the  opposite.  Dis- 
eases of  this  portion  of  the  brain-stem  are  practically  those  of  the  lower 
cranial  nerves  and  embrace  the  bulbar  palsies  already  considered  in 
Part  II. 

The  Cerebellum. — According  to  Luciani,  the  cerebellum  has  for  its 
main  function  the  maintenance  of  sthenic  tone  in  the  muscular  appara- 
tus. If  this  be  impaired,  paresis,  ataxia,  incoordination,  asthenia, 
tremors,  and  astasia  result.  It  seems  probable  that  the  cerebellmu  is 
practically  of  a  uniform  functional  quality,  which  is  quite  evenly  repre- 
sented throughout  its  entire  bulk.  One  part  may  take  the  place  of 
another.  Pisien  Pussell  ^  and  others  have  shown  that  the  right  lobe 
bears  a  certain  relation  to  the  right  side  of  the  body  and  the  left  lobe 
to  the  left  side.  Both  sides  are  probably  represented  in  the  worm,  or 
middle  lobe.  It  is  an  experimental  and  clinical  fact  that  cerebellar 
lesions  of  a  sudden    and    extensive    character    at   once    produce  very 

1  "Brit.  Med.  Jour.,"  May  18,  1895. 


184  DISEASES  OF  THE  BRAIN  PBOFEB. 

marked  ataxic  and  paretic  conditions,  which  may  in  time  entirely  pass 
away.  Lesions  similar  or  even  greater  in  extent,  but  of  slow  develop- 
ment, may  be  entirely  devoid  of  symptoms.  It  is  evident  that  the 
cerebellum  is  capable  of  rearranging  its  functional  relationships  if 
gradually  disturbed,  and  is  of  great  recuperative  powders  after  severe  in- 
jury. Much  confusion  has  arisen  from  confounding  the  symptoms  of 
the  secondary  involvement  of  adjoining  structures  with  those  purely 
cerebellar. 

We  can  now  say  that  the  right  cerebellar  hemisphere  is  in  relation 
with  the  right  side  of  the  body  and  likewise  with  the  left  cerebrum. 
Mangazzini  ^  has  shown  that  injury  to  the  thalamus  induces  atrophy  of 
the  opposite  cerebellar  half,  and  we  thus  have  a  crossed  lesion  involv- 
ing the  cerebellum  on  one  side  and  the  cerebrum  on  the  other.  With 
the  thalamic  lesion  the  corona  radiata  and  sensorimotor  cortex  are  usually 
involved. 

A  lesion  in  one  lateral  cerebellar  hemisphere,  if  occurring  with  suffi- 
cient rapidity,  as  from  hemorrhage  or  quickly  developing  abscess  or  tumor, 
produces  sthenic  loss  on  the  same  side  of  the  body.  This  becomes  mani- 
fest in  one-sided  muscular  weakness  or  readiness  of  fatigue,  in  decreased 
coordination,  in  a  tendency  to  stagger,  and  as  the  side  of  the  lesion  is  the 
weaker  side,  the  stagger  is  more  marked  in  this  direction, — that  is,  a 
patient  with  right-sided  cerebellar  disease  is  inclined  to  follow  his  right 
hand.  The  reflexes  are  also  unilaterally  reduced.  At  the  same  time  the 
trunk  may  deviate  to  the  sound  side  from  the  preponderating  muscular 
tone  on  that  side.  Weakness  of  the  ocular  muscles  on  the  same  side  as 
the  lesion  produces  a  tendency  of  the  eyes  to  deviate  in  the  opposite 
direction,  and  strong  attempts  to  turn  them  toward  the  side  of  the  lesion 
often  develop  nystagmic  or  jerky  movements.  It  seems  probable  that 
lesions  toward  the  head  of  the  worm  produce  a  tendency  to  fall  forward, 
those  toward  the  tail  of  the  worm,  a  backward  falling.  These  are  the 
paretic  manifestations.  The  cerebellar  stagger  and  the  ocular  disturb- 
ance are  often  attended  by  vertigo  of  a  pronounced  subjective  sort.  Very 
commonly  this  is  greatly  intensified  if  the  patient  attempts  to  stand  or 
even  to  sit  up,  and  may  prevent  his  doing  so.  In  other  cases,  when  the 
so-called  cerebellar  gait  is  well  marked,  there  is  no  attending  vertigo. 
Vertigo  of  a  similar  character  may  attend  a  tumor  in  the  frontal  region, 
which  at  the  same  time  may  cause  an  occipital  headache  and,  according 
to  Williamson,'^  in  one-fifth  of  such  cases  induces  bilateral  weakness  of 
the  reflexes. 

Irritative  lesions  produce  another  group  of  symptoms.  They  are 
marked  by  muscular  stiffness  in  the  extremities  of  the  same  side,  by  nys- 
tagmus, in  which  the  jerk  is  towaixl  the  side  of  the  lesion,  and  by  such 
an  arching  of  the  body  witli  the  concavity  to  the  diseased  side  as  tonic  ex- 
cess on  the  affected  side  would  produce.  Emprosthotonos  and  opisthotonos 
would  perhaps  point  to  the  middle  lobe  or  to  both  lobes.  Drummond^ 
has  also  noted  convulsions  of  a  tetanoid  character  on  the  same  side  as  the 

1  "Neurol.  Centralbl.,"  Aug.  1,  1895. 

2  "Glasgow  Med.  Jour.,"  Nov.,  1899. 
8  "Lancet,"  July  28,  1894. 


CEREBRAL    WHITE  MATTER,  BASAL  GANGLIA,  CEREBELLUM.     185 

lesion,  and  Ferrier  has  recorded  them  in  animals  subjected  to  operation. 
The  activity  of  the  lesion  dominates  the  symptoms.  They  grade  oif  in 
proportion  as  the  diseased  process  is  slow  and  may  easily  reach  a  vanish- 
ing-point in  chronic  conditions  that  sometimes  are  astonishingly  extensive. 
A  third  group  of  symptoms  arises  from  extension  of  the  cerebellar 
disease  to  neighboring  structures,  or  from  pressure  upon  them.  A  one- 
sided cerebellar  tumor,  for  instance,  by  extension  forward  above  the 
medullary  decussation,  presses  upon  the  motor  tract  from  the  cerebrum 
to  the  cord  and  gives  rise  to  spastic  symptoms  on  the  side  opposite  the 
lesion,  with  increased  myotatic  irritability  and  even  a  tendency  to  con- 
tractures. Pressure  upon  the  floor  of  the  fourth  ventricle  may  afl^ect  the 
nuclei  of  the  cranial  nerves  and  give  rise  to  paralysis  of  the  fifth,  sixth, 
seventh,  eighth,  ninth,  tenth,  and  twelfth  pairs  of  cranial  nerves.  The 
eighth  or  auditory  nerve  is  particularly  liable  to  be  affected,  and  then 
aural  symptoms  are  added.  Tinnitus  and  vertigo  of  the  Meniere  variety 
may  be  superinduced,  adding  greatly  to  the  complexity  of  the  clinical 
picture.  It  is  needful  to  investigate  the  aural  condition  very  critically, 
as  aural  vertigo  and  cerebellar  disease  are  often  associated  by  the  ex- 
tension to  the  cerebellum  of  septic  processes  in  the  ear,  and  labyrinthine 
disease  may  closely  imitate  a  cerebellar  lesion.  Irritation  in  the  fourth 
ventricle  may  produce  polyuria  and  glycosuria.  Obstruction  of  the 
Galenic  veins  produces  dropsy  of  the  ventricles,  their  distention,  and  all 
the  manifestation  of  intracranial  pressure.  Sudden  death  may  follow 
disturbance  of  the  pneumogastric  nuclei.  If  the  middle  peduncle — the 
peduncle  to  the  pons — be  affected,  forced  movements  result  and  forced 
positions  are  developed.  These  seem  to  be  toward  the  opposite  side  if 
the  lesion  is  irritative  and  toward  the  same  side  if  destructive.  Other 
clinical  manifestations  are  those  common  to  all  intracranial  diseases, — 
namely,  headache,  vomiting,  optic  neuritis,  and  vertigo.  Of  these  an 
occipital  headache  is  significant  and  is  often  associated  with  a  rigidity 
of  the  neck  and  retraction  of  the  head.  Friedeberg  ^  found  this  retrac- 
tion marked  in  over  half  of  the  cases  of  cerebellar  tumor  in  Aufrecht's 
clinic.  Sensory  disturbances  are  rare.  Russell  is  inclined  to  think  they 
may  be  present  for  a  short  time  immediately  after  the  onset  of  acute 
diseases,  as  hemorrhage,  and  transient  anesthesia  is  noticed  in  operated 
animals.  Krauss,^  from  a  study  of  ninety-seven  cases  of  cerebellar 
disease,  enumerates  the  frequency  of  symptoms  in  this  order  :  "Head- 
ache, vomiting,  optic  neuritis,  vertigo,  ataxia,  asthenia,  occipital  pain 
and  tenderness,  inclination  to  turn  toward  the  side  of  lesion,  convulsions, 
and  such  secondary  symptoms  as  nuclear  paralysis,  polyuria  and  gly- 
cosuria, tremors,  and  sudden  death."  Neither  the  mind  nor  the  sexual 
desire  is  necessarily  disturbed. 

1  "  Berliu.  kliu.  Wocheus.,"  Aug.  19,  1895.     ^  "  j^  y.  Med.  Jour.,"  June  1,  1895. 


186  DISEASES  OF  THE  BRAIN  PROPER. 


CHAPTER  IV. 
FURTHER  LOCALIZING  CONSIDERATIONS. 

Lesioxs  of  the  brain  may  be  broadly  considered  as  irritative  and 
destructive.  From  this  ])oint  of  view  they  respectively  produce  increased 
and  decreased  activity  of  function.  We  find  the  best  exposition  of 
these  conditions  in  lesions  of  the  sensorimotor  cortex.  Given  a  circum- 
scribed definite  lesion,  such  as  a  spiculum  of  bone  or  a  small  tumor  that 
rather  displaces  than  destroys  the  cortical  elements  in  this  region,  and  it 
is  likely  to  so  irritate  them  that  increased  activity  is  manifested  in  the 
peripheral  area  with  which  they  are  associated.  A  limited  spasm  or  con- 
vulsion may  ensue.  If  the  irritation  be  too  long  maintained,  necrotic  or 
destructive  cortical  changes  usually  follow  and  are  marked  by  diminished 
or  completely  lost  peripheral  function, — namely,  paresis  or  paralysis. 
A  lesion  at  first  irritative  may  thus  induce  spasms  in  the  hand,  and  after 
a  time  the  hand  becomes  paretic  if  the  progress  of  the  disease  reaches  a 
destructive  grade.  Sudden  destruction  of  the  cortical  mechanism,  as  by 
hemorrhage,  causes  immediate  loss  of  power. 

Were  all  lesions  simply  destructive  or  irritative,  difficulty  in  decipher- 
ing them  would  be  greatly  reduced,  but  ordinarily  they  are  combined  in 
varying  degree.  Around  a  destructive  process  a  zone  of  irritation 
brings  new  elements  of  disturbance  into  the  symptom-field  which,  in 
turn,  may  be  replaced  by  evidence  of  extending  destruction.  Again, 
in  an  area  practically  paralytic  from  cortical  disease  convulsions  may 
occur,  perhaps  owing  to  irritation  of  remaining  but  inhibited  cellular 
elements  or  from  irritation  of  the  subcortical  tracts.  In  every  case, 
therefore,  it  is  highly  important  to  know  the  clinical  sequence  of  irrita- 
tive and  paralytic  symptoms  in  order  to  determine  the  point  of  invasion, 
the  progress  of  extension,  and  the  limits  of  the  lesion. 

This  brings  us  to  the  invasion  or  extension  symptoms.  These  are 
transient  in  the  widening  convulsive  manifestations  of  cortical  epilepsy, 
and  permanent  in  the  slow  encroachments  of  progressive  disease.  If 
we  consider  an  irritant  or  discharging  lesion  to  be  located  in  a  given 
part  of  the  cortex,  the  disturbance  to  which  it  gives  rise  spreads  in  con- 
centric and  widening  circles  to  the  adjoining  regions,  which  are  succes- 
sively upset,  and  the  peripheral  display  is  correspondingly  and  similarly 
broadeued.  The  invading  march  of  a  Jacksonian  fit  can  be  foretold  if 
we  know  its  initial  location  or  storm-center.  Concentric  rings  on  corti- 
cal diagrams  enable  us  to  grasp  this  point  firmly.  In  figure  79,  A,  a 
fit  starting  in  the  arm-center  would  next  call  forth  the  face  and  head 
movements,  then  those  of  the  trunk,  and  finally  those  of  the  lower  ex- 
tremity. Commencing  in  the  lower  extremity,  the  order  would  be  re- 
versed, as  shown  in  figure  79,  C.  These  sequences  are  in  accordance 
with  clinical  facts.     The  order  of  convulsive  invasion  is  not  one  of 


FURTHER  LOCALIZING  CONSIDERATIONS. 


187 


chance,  but  is  rigidly  doniinatcd  by  the  anatomical  and  functional  rela- 
tions of  the  cortex.  The  initial  or  m/nal  .^i/mptoia  of  a  cortical  lit, 
therefore,  becomes  highly  signilicant  as  pointing  to  the  storm-center,  the 
point  of  greatest  instability  and  usually  the  seat  of  organic  disease. 

Considerations  of  a  similar  character  sometimes  enable  us,  if  we  have 
all  the  clinical  data  available,  to  trace  a  neoplasm  from  its  origin  as  it  in- 
vades neighboring  centers,  and  to  relatively  estimate  its  anatomical  limits. 
The   area   of  latent   lesions   must  be 

kept  in  mind.      It  gives  no   special  ^      ^ 

symptoms  when  traversed  by  the 
discharge  of  a  fit  or  when  invaded 
by  a  growth.  The  cortical  fields  of 
speech  and  the  special  senses  are 
subject  to  the  same  rules  as  the  sen- 
sorimotor zone.  Their  invasion  is 
attended  by  aphasic  or  sensory  dis- 
turbances. In  the  latter  case  hallu- 
cinations are  likely  to  appear,  and 
may  constitute  the  signal  symptom 
of  Jacksonian  fits.  Thus,  patients 
may  always  hear  a  certain  sound,  see 
a  certain  spectrum,  smell  or  taste  a 
certain  article  as  the  fit  comes  on. 
In  at  least  one  such  case  the  appli- 
cation of  concentric  cortical  lines 
showed  that  the  subsequent  motor 
disturbance  was  subject  to  the  same 
invasion  rule  that  obtains  when  the 
storm  arises  in  the  central  convolu- 
tions. 

Peripheral  sensory  disturbance 
arising  from  cortical  lesions  is  usu- 
ally of  a  paresthetic  sort.  There  may 
be  some  blunting  of  cutaneous,  mus- 
cular, and  joint  sensations,  but  persis- 
tent anesthesia  is  extremely  rare 
except  in  bilateral  lesions.  The 
double  and  complete  representation 
of  sensation  has  been  sufficiently  in- 
sisted upon  (see  p.  180).  In  Jack- 
sonian fits  the  initial  symptom  is 
often  a  peculiar  sensation  or  pain 
that  is  first  thrown  into  spasm.  Patients  are  frequently  at  a  loss  to 
describe  these  sensations,  and  they  vary  from  slight  discomfort  or  slight 
formication  to  severe  pain  and  intense  burning.  Their  distribution 
is  segmental  or  functional  and  does  not  conform  to  the  peripheral 
nerve-supply.  They  are  tolerably  nniform  in  quality  and  distribution 
in  any  given  case. 

From  another  point  of  view  cerebral  symptoms  are  diffused  or  local- 


Fig.  79. — Schematio  figures  to  show  the  en- 
croachment of  waves  of  discharge  in  the  cortex, 
beginning  resi)ectively  in  tlie  arm,  face,  and 
leg  centers.  I'',  Face;  B,  arm;  J,  leg  (after 
Brissaud). 


localized    in    or    near    the    part 


188  DISEASES  OF  THE  BRAIN  PROPER. 

ized.  The  great  majority  of  endocranial  lesions  are  marked  by  headache, 
vertigo,  vomiting,  mental  disturbance,  and  often  by  optic  neuritis.  As 
these  do  not  necessarily  depend  upon  the  part  involved,  they  have  little 
localizing  value,  but  the  presence  of  several  of  them  is  highly  suggestive 
of  brain  disease. 

Headache  is  a  very  usual  symptom.  It  is  pronounced  in  the  cases 
which  involve  the  meninges.  Its  importance  in  meningitis  will  be  at 
once  recalled.  In  syphilitic  cerebral  disease  it  has  a  marked  tendency 
to  come  on  toward  night.  Cerebral  headaches  are  usually  very  intense 
and  very  refractory  to  sedatives.  Lesions  which  do  not  impinge  upon 
the  cortex  or  meninges  may  give  rise  to  no  headaches  whatever,  unless 
pressure  conditions  arise,  when  the  superficial  portions  of  the  encephalon 
are  disturbed  and  pain  ensues.  Cerebellar  disease  is  frequently  attended 
by  an  occipital  headache  and  a  tendency  to  retraction  of  the  head.  The 
location  of  the  headache  is  not  always  in  close  relation  to  the  lesion. 
For  instance,  cerebellar  disease  has  caused  intense  frontal  headaches,  and 
small  tumors  have  given  rise  to  a  generalized  head-pain.  A  circum- 
scribed, deep-seated,  persistent,  and  intense  headache,  however,  has 
some  localizing  value. 

Vertigo  attends  many  brain  disorders,  and  marks  nearly  all  cere- 
bral surprises  arising  either  from  without,  as  by  concussion,  or  from 
within,  as  from  embolism  or  hemorrhage.  Implication  of  the  aural 
apparatus  gives  rise  to  the  peculiar  vertigo  described  under  Meniere's 
Disease  (see  p.  129).  A  lesion  of  the  middle  cerebellar  peduncle  causes 
forced  lateral  movements,  usually  associated  with  vertiginous  sensations, 
and  cerebellar  disease  is  marked  by  a  stagger,  into  the  causation  of  which 
some  vertigo  may  enter.  In  a  general  way  we  may  say  that  persistent 
vertigo  is  likely  to  be  allied  to  diseases  of  the  basal  parts.  These,  too, 
may  give  rise  to  the  ocular  and  labyrinthine  forms  from  injury  to  the 
motor  nerves  entering  the  orbit  or  vestibule. 

Vomiting  in  encephalic  disease  is  a  common  symptom.  The  pecu- 
liarities which  mark  cerebral  vomiting  are  lack  of  gastric  disorder  and 
nausea,  a  clean  tongue,  and  the  readiness  and  ease  with  which  the 
stomach  rejects  its  contents.  There  is  very  little  retching,  and  the  food 
or  drink  is  regurgitated,  sometimes  with  considerable  force,  in  a  projectile 
manner.  Meningeal  invasions  of  an  inflammatory  or  other  character 
often  present  this  symptom.  It  is  very  common  in  disease  of  the  cor- 
pora quadrigemina,  the  pontine  and  the  cerebellar  regions,  perhaps  from 
more  or  less  irritation  of  tlie  pneumogastric  nucleus. 

All  varieties  of  mental  disturbance  appear  in  organic  brain  disease. 
We  encounter  momentary  unconsciousness  in  petit  mal ;  hebetude,  and 
profound  coma  in  meningitis,  apoplexy,  concussion,  and  intracranial 
pressure  ;  maniacal  disturbance  after  epileptic  attacks  ;  changed  tempera- 
ment and  character  after  frontal  lesions,  and  more  or  less  dementia  in 
nearly  all  cerebral  paralytics.  The  diffuse  cerebritis  of  general  paresis 
presents  its  own  usually  highly  colored  mental  picture.  The  mental 
attributes  of  aphasics  have  been  already  described.  Mental  symptoms 
have  the  same  general  significance  as  motor  signs.  Irritation  means 
mental  excitement,  and  overmental  excitement  leads  to  hebetude,  which 


FURTHER  LOCALIZING  CONSIDERATIONS.  189 

also  directly  follows  pressure  eonditions,  shock,  and  deranged  cerebral 
circulation. 

Optic  neuritis  in  brain  disease  has  been  adverted  to  under  Diseases  of 
the  Optic  Nerve  (see  p.  96).  Its  presence  in  suspected  intracranial 
tumor  almost  serves  to  clinch  the  diagnosis.  The  location  of  a  growth 
or  the  position  of  an  abscess,  or  their  size,  seems  to  have  very  little  to  do 
with  the  intensity  of  the  papillitis,  but  it  is  most  common  in  lesions  of 
the  basal  ganglia  and  cerebellum.  When  unilateral,  the  growth  is  com- 
monly on  the  same  side  of  the  brain.  A  neuroretinitis  is  a  common 
symptom  and  sequence  of  meningitis. 

The  localizing  symptoms  of  brain  disease  have  been  set  forth  in  the 
three  preceding  chapters.  In  addition  we  often  derive  much  infor- 
mation from  the  implication  of  the  cranial  nerves  that  takes  place  in  their 
intracranial  course.  The  various  symptoms  thus  produced  are  discussed 
under  Diseases  of  the  Cranial  Nerves.  Diseases  of  the  base,  the  pedun- 
cular, pontine,  and  medullary  portions  of  the  encephalon  ordinarily  have 
cranial-nerve  concomitants.  This  is  also  true  of  lesions  of  the  cere- 
bellar peduncles  and  of  other  parts  in  the  region  of  the  series  of  cranial- 
nerve  nuclei. 

Topical  symptoms  of  some  value  are  often  encountered  in  intracranial 
disease,  and  should  always  be  sought.  Traumata,  if  recent,  are  usually 
marked  by  bruises,  wounds,  or  fractures  that  at  once  center  attention  on 
the  underlying  parts  and  on  the  opposite  side  of  the  brain  where  the 
force  of  the  blow  is  expended.  In  later  cases  scars,  cranial  depressions, 
or  evidence  of  bone  disease  are  equally  significant.  The  presence  of 
deformities  due  to  new  growths  and  the  conditions  of  the  auditory  canals, 
nasal  passages,  and  pharyngeal  vault  are  to  be  carefully  noted.  When 
the  disease  affects  the  meninges  there  is  often  topical  pain  and  tenderness 
that  can  be  elicited  by  making  pressure  over  the  scalp  or  by  going  over 
the  surface  with  a  percussion  hammer.  Its  outline  and  permanence  are 
suggestive  of  the  extent  of  disease  beneath.  A  neuralgia  of  the  fifth  or 
occipital  nerve  has  its  own  tender  points  and  anatomical  outlines  to  dis- 
tinguish it.  By  percussion,  Macewen,  Starr,  and  others  have  been  able 
to  distinguish  a  diiferent  note  over  the  seat  of  intracranial  growths  and 
diseases  that  were  located  close  to  the  cranial  wall.  This,  doubtless, 
requires  a  very  acute  ear,  but  should  be  sought  in  every  suspicious  case. 
Intracranial  aneurysms  may  in  some  cases  present  a  bruit  that  can  be 
heard  through  the  stethoscope.  We  would  naturally  expect  the  patient 
to  be  aware  of  it,  as  the  conditions  favorable  for  bone-conduction  would 
be  present.  Two  of  the  writer's  cases  of  extensive  intracranial  aneur- 
ysm, in  which  a  bruit  was  probably  present,  gave  expression  to  no  such 
subjective  complaint,  and  auscultation  was  not  attempted  before  opera- 
tion. In  a  third,  persistent  throbbing  had  annoyed  the  patient  for 
months  and  then  disappeared,  but  the  stethoscope  revealed  a  decided 
bruit,  of  which  she  was  not  conscious. 

In  some  cases  of  intracranial  disease  a  localized  elevation  of  tempera- 
ture has  assisted  the  diagnosis.  Our  present  commonly  available  means 
of  surface  thermometry  are  deficient  in  accuracy.  If  the  bulbs  of  clinical 
thermometers  be  passed  through  pieces  of  rubber  protective  and  then 


190  DISEASES  OF  THE  BRAIN  PROPER. 

applied  to  the  scalp  by  light  bandages,  tolerably  reliable  readings  may 
be  obtained.  It  must  be  borne  in  mind  that  the  left  side  of  the  head 
is  usually,  in  the  right-handed,  about  one  degree  warmer  than  the  right 
side,  and  that  mental  activity  causes  the  temperature  to  go  up  nearly  or 
quite  another  degree.  Sometimes  in  suspected  abscess  a  thermometer  in 
each  auditory  canal  may  on  one  side  show  local  heat  even  in  the  absence 
of  any  apparent  local  inflammation.  Palpation  may  discover  a  brain 
tumor,  as  the  cranial  wall  is  often  eroded  by  a  cerebral  growth,  and  that, 
too,  when  situated  at  a  considerable  depth. 

Finally,  it  is  to  be  borne  in  mind  that  a  brain-lesion  located  in  a 
latent  zone  may  give  rise  to  symptoms  at  a  distance.  In  some  instances 
this  results  from  interference  with  the  blood-supply  or  the  return  circu- 
lation. In  other  cases  the  mechanism  can  not  be  explained.  In  many 
cases  where  every  symptom  pointed  to  the  cortex,  the  disease  has  been 
found  deeply  seated.  The  localizing  diagnosis  always  contains  uncer- 
tainties and  should  be  expressed  with  a  fair  degree  of  reservation. 
Operations  depending  on  it  are,  therefore,  exploratory  in  every  instance 
when  external  guiding  signs  are  lacking. 


ARTERIAL   BRAIN  DISEASES. 


191 


CHAPTER  V. 
ARTERIAL  BRAIN  DISEASES. 

In  the  preceding  chapters  of  this  part  the  localizing  features  of  brain 
disease  have  been  considered.  They  furnish  the  basis  of  the  localizing 
diagnosis.  An  equally  or  more  important  question  is  that  of  the  patho- 
logical diagnosis.  What  is  the  lesion  ?  Comparatively  few  pathological 
processes  are  found  in  diseases  of  the  brain,  but  their  effects  and  re- 
sults are  numerous  and  serious.  These  diseases  fall  into  groups  related 
to  :  (1)  The  arterial  supply  ;  (2)  the  venous  return  ;  (3)  inflammatory 
disturbances  of  the  brain-substance,  and  (4)  new  formations.  Surgical 
conditions,  such  as  penetrat- 
ing wounds,  are  left  to  works 
properly  covering  such  acci- 
dents. We  first  turn  our  atten- 
tion to  the  arterial  supply  of  the 
brain. 

Anatomical  Considera- 
tions.— The  arterial  supply 
of  the  encephalon  furnishes 
the  anatomical  basis  of  some 
brain-lesions,  and  presents  prac- 
tical points  of  great  impor- 
tance. The  left  carotid,  leav- 
ing the  arch  of  the  aorta  on 
a  tangent  that  conforms  to  the 
natural  blood-current,  favors 
the  passage  of  emboli  of  car- 
diac origin  to  the  left  brain. 
It  will  be  recalled  that  all 
the  blood    to  the   brain  proper 

reaches  the  encephalon  by  the  internal  carotids  and  the  vertebrals. 
These  four  inlets  are  brought  into  intimate  relation  through  the 
circle  of  Willis.  From  side  to  side  compensation  in  the  circle 
is  practically  complete  in  case  the  lateral  arteries  are  occluded. 
From  the  carotid  or  anterior  portion  of  the  circle  to  the  verte- 
bral, basilar,  or  posterior  portion,  full  compensation  can  not  be 
provided  owing  to  the  smallness  of  the  connecting  arteries.  From 
the  circle  of  Willis  two  distinct  systems  of  arteries  arise, — the 
basal  and  the  cortical.  From  the  circle  itself,  and  from  about 
the  first  inch  of  the  six  great  arteries,  the  anterior,  middle,  and 
posterior  cerebrals,  short,  direct  vessels  plunge  into  the  brain  to 
nourish  the  basal  parts,  ganglia,  and  capsules.  These  anastomose  but 
slightly  with  one  another,  and  are  of  the  nature  of  terminal  arteries. 
Their    occlusion     or    destruction     irreparably    cuts    off    the     circula- 


Fig.  80. — Charcot's  diagram  of  Uie  circulation  at  the 
base  of  the  brain. 


192 


DISEASES   OF  THE  BRAIN  PROPER. 


tion  from  a  given  portion  of  brain-tissue.  Those  distributed  to  the 
lenticulostriate  nucleus,  the  internal  capsule,  and  a  portion  of  the 
thalamus  are  derived  from  the  stem  of  the  middle  cerebral.  One 
in  particular,  supplying  the  third  layer  of  the  lenticular  ganglion, 
the  caudate  nucleus,  and  the  upper  portion  of  the  capsule,  is  so 
commonly  the  seat  of  rupture  that  it  has  been  denominated  by 
Charcot  the  artery  of  cerebral  hemorrhage. 


Fig.  81. — Distribution  of  the  middle  cerebral  artery  (Duret). 

The  main  cerebral  arteries  coursing  up  over  the  hemispheres  in  the 
arachnopia  have  each  a  definite  cortical  territory,  and  these  only  slightly 
overlap.  They  give  oif  two  sets  of  branches, — namely,  delicate  arteri- 
oles, nourishing  the  cortex,  which  they  enter  at  right  angles,  and  larger 
straight,  long  branches,  which  pierce  the  cortex  and  supply  the  white 
matter  of  the  cerebrum  (see  Fig.  67,  p.  161).     These  pass  inw^ard  and 


Fig.  82. — Showing  the  distribution  of  the  anterior,  middle,  and  posterior  cerebral  arteries  on  the 
surface  of  the  brain.  The  numerals  I,  II,  III,  IV  indicate  the  areas  supplied  by  the  different  branches; 
the  dotted  lines  indicate  the  main  trunks  (modified  from  Merkel  and  Debierre). 


almost  come  into  ana.stomotic  contact  with  the  upward-reaching  termina- 
tions of  the  capsular  and  ganglionic  branches  arising  close  to  the  circle. 
Between  these  arterial  territories  there  remains  an  ill-nourished  zone 
that  is  prone  to  senile  softening  (Fig.  83). 

The  cereljellum  receives   its  l)lood-supply  from  the  vertebrals  and 
basilar  ;  the  medulla  and  pons  are  largely  supplied  by  the  basilar.      It 


ARTERIAL   BRAIN  DISEASES. 


193 


will  be  recalled,  from  the  description  of  the  jjial  vessels  (p.  72),  that 
their  cortical  and  deeper  branches  carry  with  them  a  periarterial 
lymph-sheath  continuous  with  the  pial  space. 


CEREBRAL  ANEMIA  AND  HYPEREMIA. 

Cerebral  Anemia. — Until  recently  an  undue  importance  attached 
to  the  frequently  alleged  conditions  of  general  brain  anemia  and 
hyperemia.  They  were  spoken  of  as  morbid  entities,  and  diag- 
nosis stopped  at  that.  We  must  look  upon  them  as  purely  symp- 
tomatic and  secondary.  In  many  respects  they  are  marked  by 
similar  or  even  identical  phenomena,  and  can  only  be  distinguished  by 
their  associated  states  or  incidental  symptoms.  The  circulation  of  the 
brain,  it  will  be  recalled,  is  under  the  direct  control  of  vasomotor  centers 
in  the  medulla  and  cervical  cord. 


^ 


•'-f- 


It  is  exceedingly  difficult,  if  not 
impossible,  to  say  where  physio- 
logically increased  blood-supply 
becomes  a  morbid  congestion  and 
entitled  to  the  term  hyperemia. 
Cerebral  anemia  is  equally  indefi- 
nite. In  giving  the  causes  of  these 
opposite  conditions,  therefore,  it 
has  been  found  impossible  to 
sharply  separate  the  natural  from 
the  morbid  states.  Let  us  first 
consider  the  anemic  brain. 

Etiolog-y. — Cerebral  anemia 
is  most  common  in  infancy  and 
old  age,  the  periods  of  least  brain 
activity.  In  old  age  it  is  the 
legitimate  consequence  of  senile 
arterial  degeneration.  In  adults 
it  follows  intense  emotions, various 
peripheral,  acute,  painful  disturb- 
ances, and  shock  of  all  sorts.  Tobacco,  ergot,  belladonna,  bromids,  anti- 
mony, lead,  chloroform,  and  many  other  drugs  and  poisons  produce  cere- 
bral anemia.  Fatty  heart,  aortic  insufficiency,  bradycardia,  excessive 
hemorrhage,  rapid  evacuation  of  peritoneal  and  pleural  effusions  are 
attended  by  cerebral  anemia.  It  takes  a  prominent  place  in  all  the 
general  anemias,  and  in  the  pernicious  varieties  is  especially  marked  and 
often  attended  by  nutritional  changes  in  the  gray  matter  of  the  brain 
and  spinal  cord.  Cachectic  and  exhausting  diseases,  such  as  cancer, 
typhoid,  phthisis,  etc.,  produce  a  similar  condition.  Ligature  or  oblitera- 
tion of  a  carotid,  or  partial  occlusion  of  both  carotids  or  vertebrals  by 
atheroma,  serve  to  mechanically  produce  anemia  of  the  brain. 

Symptoms. — In  acute  forms  of  brain  anemia,  such  as  are  typified 
by  an  ordinary  fainting  spell  or  a  great  loss  of  blood,  the  symptoms  are 
13 


Fig.  83.— Scheme  showing  the  anastomotic  re- 
lations of  the  basilar  and  cortical  arterial  supplies. 
A,  Common  location  of  senile  softening ;  B,  com- 
mon location  of  cerebral  hemorrhage  (after  Bris- 
saud). 


194  DISEASES   OF  THE  BRAIN  PROPER. 

"  darkness  before  the  eyes/'  giddiness  or  vertigo,  noises  in  the  ears, 
feebleness,  trembling  of  the  limbs,  nausea  or  vomiting,  sometimes  slight 
delirium,  and  then  more  or  less  loss  of  consciousness.  Partial  or 
generalized  convulsive  movements  are  common,  and  epileptiform  con- 
vulsions are  sometimes  seen.  Finally  the  condition  remits  or  passes 
deej)er  into  coma,  and  may  terminate  in  death.  The  face  is  usually 
blanched,  the  pulse  small  and  fluttering,  the  pupils  dilated,  the  skin  cov- 
ered with  a  cold  perspiration.  Similar  conditions  are  seen  in  shock,  and 
to  a  moderate  degree  in  some  cases  of  migraine. 

In  the  chronic  form,  such  as  attends  general  anemia  and  the  cachexise, 
patients  complain  of  heaviness  of  the  head,  of  headaches  limited  to^  a 
portion  of  the  head,  or  a  feeling  of  constriction  about  the  head.  They 
sleep  lightly  or  brokenly  and  their  sleep  is  disturbed  by  dreams.  There 
is  mental  and  physical  inertia.  They  are  irritable,  peevish,  impression- 
able, and  somnolent.  The  pupils  are  dilated.  Vertigo,  sometimes 
ringing  in  the  ears,  and  muscse  volitantes  are  common,  and  often  induced 
by  rising  from  the  recumbent  position  or  by  a  quick  turn  of  the  head. 
In  extreme  cases  there  may  be  visual  hallucinations  and  temporary  blind- 
ness from  retinal  anemia.  Slight  delirium  or  maniacal  states  and  even 
epileptiform  convulsions  are  seen  in  severe  instances.  Optic  papillitis 
or  choked  disc  is  occasionally  encountered. 

The  diagnosis  is  not  difficult  except  in  the  toxic  cases.  It  must 
be  remembered  that  the  circulation  in  the  face,  or  even  in  the  retina,  is 
not  a  reliable  index  of  the  brain  state,  but  is  sometimes  a  helpful  guide. 
Anemia  of  the  brain  is  relieved  by  placing  the  head  low  and  intensi- 
fied by  the  vertical  attitude. 

The  treatment  is  that  of  the  underlying  causal  state  or  toxic  con- 
dition. 

Cerebral  hyperemia,  like  anemia  of  the  brain,  is  always  a  secondary 
state,  and,  while  arising  from  opposite  conditions,  has  many  similar  sub- 
jective symptoms.  It  may  be  recalled  that  the  passing  from  sleep  to 
the  waking  state  is  normally  marked  by  increased  cerebral  circulation, 
as  is  also  the  process  of  active  mentation,  which  is  attended  by  a  slight 
increase  in  the  surface  temperature  of  the  head,  particularly  on  the  left 
side  in  right-handed  persons.  The  brain  volume  is  augmented  and  in- 
tracranial cerebrospinal  fluid  is  displaced  in  cerebral  congestion. 

Etiolog-y. — Muscular  effort,  coughing,  vomiting,  increased  heart 
action,  impeded  respiration,  a  dependent  position  of  the  head, — all  tend 
to  increase  the  amount  of  blood  within  the  skull  and  produce  congestion 
or  hyperemia  of  the  brain.  Usually  the  face  shows  a  similar  condition. 
Some  families  display  a  tendency  to  plethora  and  cerebral  congestion. 
Menstrual  periods  are  normally  marked  by  an  increased  circulation  in 
the  brain.  At  the  climacteric  this  occurs  in  flushes  or  waves  and  be- 
comes very  annoying.  Gouty  subjects  are  particularly  liable  to  vas- 
cular disturbance,  which  frequently  involves  the  cerebral  circulation. 
Contracted  kidney  and  arteriosclerosis  are  also  commonly  marked  by 
such  vascular  storms.  Insolation  produces  intense  cerebral  congestion, 
and  exposure  to  cold  has  a  similar  effect  by  driving  the  blood  from  sur- 
face to  center.  In  the  same  way  during  a  chill  the  central  organs  are 
hyperemic.     The  nitrites,  opium,  alcohol,  and  the  infections  of  typhoid, 


ARTERIAL   BRAIN  DISEASES.  195 

pnouinonia,  tetanus,  and  many  fevers  produce  cerebral  congestion.  This 
may  alone  be  the  cause  of  the  convulsions  which  so  frequently  mark  the 
onset  of  eruptive  fevers  in  children.  The  suppression  of  menstrual 
discharges  or  of  chronic  hemorrhoidal  bleeding  and  pressure  on  the  aorta, 
by  a  tumor  or  fecal  accimiulation  raises  the  cerebral  blood-pressure. 
Cardiac  conditions  may  cause  cerebral  congestion  by  impeding  the 
venous  return  or  increasing  the  arterial  tension.  Inflammations  about 
the  head  and  neck  and  in  the  throat  are  commonly  attended  by  cerebral 
congestion.  Brain-tumors  and  continued  epileptic  attacks  usually  cause 
increased  cerebral  vascularity. 

Symptoms. — Acute  cerebral  congestion  of  a  marked  degree  usually 
causes  intense  throbbing  headache,  haziness  or  blurring  of  vision,  and 
sometimes  photophobia.  It  sometimes  leads  to  vertigo,  ringing  or 
throbbing  in  the  ears,  a  tendency  to  somnolence,  and  if  sleep  ensues, 
frightful  dreams  are  likely  to  disturb  it.  There  is  mental  clepression 
and  incapacity  for  thought. 

Acute  cerebral  congestion  in  a  grave  form  occasionally  comes  on  like 
an  apoplectic  stroke  and  furnishes  an  apoplectic  equivalent.  The  patient 
falls  inert,  unconscious,  with  stertorous  respiration,  relaxation  of  the 
sphincters,  and  may  die.  He  usually  recovers,  however,  in  a  day  or  two. 
Slight  paralytic  symptoms  last  several  days  longer  and  eventually  com- 
pletely disappear.  All  gradations  of  cerebral  congestive  attacks  are 
encountered,  and,  as  above  indicated,  it  is  often  difficult  to  distinguish 
at  ^vhat  point  they  become  pathological. 

In  gouty  cases  and  in  various  chronic  intoxications  there  is  a  tend- 
ency in  some  to  delirium,  in  others  to  convulsive  manifestations,  during 
the  attack  of  cerebral  hyperemia.  These  motor  and  mental  excesses 
may  reach  epileptoid  and  maniacal  stages. 

Chronic  hyperemia  of  the  brain  is  usually  a  part  of  organic  disease  of 
that  organ  and  does  not  here  call  for  special  mention,  as  its  symptomatic 
value  is  commonly  apparent.  When  it  gives  rise  to  symptom  groups  it 
is  by  exacerbation  in  the  form  of  acute  attacks. 

The  diagnosis  of  cerebral  congestion  is  commonly  easy.  The  feel- 
ing of  fullness  in  the  head,  the  injected  eyes,  the  flushed  face,  full  arter- 
ies, quickened  pulse,  contracted  pupils,  and  the  increase  of  all  symptoms 
when  the  head  is  lowered  are  sufficiently  striking.  It  is  often  very 
difficult,  however,  to  distinguish  the  epileptoid  and  apoplectiform  attacks 
from  those  of  pure  epilepsy  and  gross  brain-lesions  respectively.  In 
the  case  of  apoplectiform  attacks  in  plethoric  individuals  before  the  age 
of  fifty,  especially  if  they  are  alcoholic  or  gouty,  the  presumption  is  in 
favor  of  cerebral  congestion  and  reservation  of  opinion  is  in  order.  In 
epileptiform  attacks  the  history  of  the  case  will  almost  invariably  illumi- 
nate the  situation. 

The  symptom,  hyperemia,  having  been  deciphered,  it  remains  to  trace 
it  to  its  proper  source,  and  to  this  treatment  is  directed.  Repeated  cere- 
bral congestive  attacks  in  elderly  persons  foreshadow  cerebral  hemor- 
rhage and  softening.  In  paretic  dementia  they  are  likely  to  be  followed 
by  apoplectiform  attacks  and  a  rapid  downward  course.  In  other  in- 
stances their  significance  is  strictly  related  to  their  cause. 


196  DISEASES   OF  THE  BRAIN  PROPER. 


CEREBRAL  ARTERITIS. 


Immense  importance  attaches  to  disease  of  the  cerebral  arteries,  not 
so  much  on  their  own  account  as  because  of  the  dire  consequences  of 
hemorrhage  and  softening  which  they  may  entail. 

Acute  arteritis  in  the  brain  may  follow  infectious  diseases,  such  as 
typhoid,  variola,  diphtheria,  scarlet  fever,  measles,  and  puerperal  infec- 
tion. All  the  arterial  tunics  are  involved,  but  distinct  symptoms  do  not 
arise  unless  thrombosis  ensues.  This  is  particularly  liable  to  occur,  as 
the  intima  is  often  much  thickened.  The  arterial  inflammation  in  many 
instances  arises  first  in  the  vasa  vasorum,  and  is  thence  propagated 
to  the  arterial  -  trunks.  The  softening  that  ensues  may,  according  to 
Turner,  be  followed  by  cerebral  hemorrhage. 

Peri-arteritis  is  a  descriptive  term  apjalied  to  a  proliferating  affec- 
tion involving  the  external  arterial  coat.  It  is  attended  by  diffuse  or 
circumscribed  thickenings  and  connective-tissue  increase.  The  perivas- 
cular sheaths  of  the  cerebral  vessels  become  choked.  This,  taken  with 
the  weakened  arterial  wall,  favors  the  formation  of  saccular  dilatations. 
In  many  instances  the  cerebral  vessels  become  beaded  with  minute  aneur- 
ysms, which  are  prone  to  develop  at  the  branching  points.  In  them- 
selves these  miliary  aneurysms  favor  rupture,  and  the  fatt}^  degeneration 
of  the  arterial  and  capillary  walls  increases  this  danger.  As  a  fact,  they 
are  the  almost  invariable  source  of  cerebral  hemorrhage,  and  can  usually 
be  found  by  carefully  washing  out  the  clot. 

Peri-arteritis  is  frequently  caused  by,  or  at  least  associated  with, 
Bright's  disease.  It  may  be  induced  by  tubercular  infection,  which 
usually  invades  the  cranium  by  the  arterial  route.  It  is  a  concomitant 
of  the  involution  of  advanced  years  and  of  arteriosclerosis.  Syphilis 
may  produce  it,  as  may  gout,  rheumatism,  and  alcohol.  Symptoms  are 
very  vague  and  indefinite,  or  absent,  until  hemorrhage  or  infarction  gives 
rise  to  plegic  disturbances.  The  condition  should  be  suspected  in  chronic 
Bright's  disease  and  in  cases  showing  arterial  degeneration  elsewhere. 

Chronic  arteritis,  atheroma,  endarteritis  deformans,  is  frequently 
found  in  the  large  cerebral  vessels,  particularly  those  at  the  base, 
and  especially  the  basilar.  The  atheromatous  plaque  originates  in 
the  occlusion  or  inflammation  of  the  nutrient  artery,  or  vasa  vasorum. 
This  produces  an  infarct  largely  confined  to  the  middle  tunic  of  the  ves- 
sel, and  the  fatty  degeneration  that  ensues  is  eventually  replaced  by 
calcareous  deposits.  The  vessel  may  be  completely  encircled  by  such 
a  patch,  or  numerous  atheromatous  islands  may  be  found.  By  their 
coalescence  the  entire  artery  becomes  rigid  and  brittle.  At  first  the 
intima  covers  the  plaques  smoothly,  but  it  is  prone  to  break  down,  leav- 
ing the  calcareous  matter  exposed  in  the  blood-stream.  This  frequently 
leads  to  local  deposits  of  fibrin  from  the  blood,  which  may  cause  throm- 
botic closure  of  the  vessel  or  wash  away  in  embolic  masses  or  particles, 
to  produce  disturbance  farther  along  the  course  of  the  arterial  current. 
In  the  same  way  calcareous  particles  may  be  cast  into  the  stream,  and, 
lodging  in  the  narrowing  channel,  cause  secondary  mischief.  An- 
other effect  of  atheroma  is  to  narrow  the  lumen  of  the  affected  vessel 


ARTERIAL   BRAIN  DISEASES.  197 

through  tlie  thickening  of  its  walls  and  the  swelling  of  the  internal  coat. 
Again,  by  weakening  the  vessel-wall,  atheroma  may  produce  dilata- 
tion and  lead  to  an  aneurysm.  The  small  arteries  arising  at  the  seat  of 
atheromatous  invasion  may  be  occluded,  though  the  parent  vessel  re- 
mains pervious.  Collateral  territories  are  thus  cut  off,  while  the  ulti- 
mate distribution  remains  active.  The  rigidity  and  brittleness  of  the 
artery  favor  rupture  and  hemorrhage. 

Atheroma  may  be  considered  as  a  purely  senile  condition  in  many 
cases,  a  part  of  the  involutionary  changes  of  the  organism  in  advanced 
years.  There  is  no  doubt  that  gout,  rheumatism,  great  muscular  strain- 
ing, overindulgence  in  alcohol,  lead  poisoning,  and  syphilis  are  addi- 
tional causes.  Lancereaux  says  chronic  malarial  infection  may  cause 
atheroma.  Causes  are  frequently  combined  in  a  given  case,  as  gout 
and  senility.  Atheroma,  though  usually  found  after  middle  life, 
has  been  noted  in  the  aorta  and  large  systemic  vessels  in  children  and 
even  in  infants. 

The  symptoms  of  atheroma  of  the  cerebral  vessels  are  usually  vague 
and  uncertain  until  thrombosis,  aneurysm,  or  hemorrhage  has  been  added. 
It  may  be  reasonal^ly  suspected  when  the  condition  in  the  heart,  aorta, 
and  palpable  systemic  arteries  indicates  its  generalized  distribution. 
Protracted  nosebleed  after  middle  life  is  generally  due  to  arterial  de- 
generation of  carotid  branches  in  the  nasal  spaces  and  a  rather  common 
forerunner  of  cerebral  arterial  accident.^  Lesion  of  the  optic  chiasm 
by  bilateral  atheromatous  thickenings  of  the  carotids  pressing  upon  it 
has  been  noted.  Double  temporal  hemianopsia  may  thus  be  produced. 
The  formation  of  an  aneurysmal  tumor  gives  rise  to  its  own  localizing 
symptoms.  Resulting  hemorrhage  and  thrombosis  present  symptoms 
related  to  the  structures  that  are  injured  or  destroyed. 

The  treatment  of  atheroma  is  practically  the  same  as  that  of  arterio- 
sclerosis. 

Arteriosclerosis,  arteriocapUlary  fibrosis,  is  always  a  general- 
ized systemic  condition,  but  it  may  be  more  accentuated  in  certain 
bodily  organs  and  there  give  rise  to  local  symptom  groups.  Its  effect 
upon  cerebral  activity  is  most  important.  According  to  Sansom,  the 
changes  brought  about  are  due  to  a  poison  circulating  in  the  blood,  which 
acts  upon  the  fibroid  elements  of  various  tissues,  but  preeminently  upon 
those  of  the  arterial  channels.  The  essential  histological  modification 
consists  of  a  fibroid  proliferation  or  fibrosis.  In  certain  locations  this 
acts  mechanically  to  strangulate  associated  structures,  as,  for  instance,  in 
the  arteries,  where  the  muscular  fibers  are  thus  invaded  and  even  dis- 
placed. The  walls  of  the  entire  arterial  system  become  thickened. 
This  may  be  due  :  (1)  To  thickening  of  the  internal  coat,  which  may  go 
on  to  the  complete  obliteration  of  small  vessels,  or  (2),  commencing  first 
in  the  external  wall,  the  disease  may  spread  inward,  usually  causing  at 
first  some  hypertrophy  of  the  muscular  coat,  or  (3)  the  fibrosis  may 
originate  outside  of  the  arterioles,  which  are  involved  secondarily  by 
extension  of  the  process  to  them.  The  various  initial  locations  of  the 
disease  seem  to  depend  upon  the  mode  of  the  poisonous  invasion.  In 
^  K.  Kompe,  "Arch.  f.  LaryngoL,"  1899. 


198 


DISEASES  OF  THE  BRAIN  PROPER. 


one  instance  it  affects  the  intima  directly  from  the  blood-stream,  in 
another  the  outer  coat  from  the  perivascular  or  lymphatic  space,  and  in 
the  third  variety  the  fibrous  structures  of  parenchymatous  organs  are 
disturbed  through  the  lymph-channels.  All  these  varieties  may  be 
found  in  the  same  case. 

This  condition  has  a  number  of  pathological  associations.  Atheroma 
is  present  in  about  one-half  the  cases.  Cardiac  hypertrophy  and  dilata- 
tion, hepatic  cirrhosis,  Bright's  disease,  asthma,  angina  pectoris,  and 
mitral  stenosis  are  frequently  associated  and  due  to  identical  changes. 
The  effect  of  arteriosclerosis  is  to  diminish  the  arterial  caliber  and 
thereby  lessen  nutrition.  This  may  reach  a  complete  degree  and  in  the 
brain  give  rise  to  localized  anemia  and  softening. 

The  nature  of  the  poison  which  stimulates  the  fibroid  activity  is 
obscure.  Loomis  says  the  "  general  fibrosis  has  its  origin  in  a  fibroid 
diathesis  either  hereditary  or  acquired,"  but  this  explains  nothing.  By 
some  writers  defective  elimination,  particularly  that  from  the  kidney,  is 
accused.  Arteriosclerosis  is  certainly  an  accompaniment  of  old  age  and 
is  a  fair  index  of  the  wear  and  tear  the  individual  has  undergone  and  of 


Fig.  84.— Arteritis  :  thickening  of  all  the  coats  (Delafield). 


the  remaining  vital  capacity.  We  find  it  often  a  marked  family  charac- 
teristic. It  is  also  clear  that  chronic  intoxications  by  alcohol,  lead,  gout, 
rheumatism,  and  syphilis  favor  it  strongly.  Overeating,  repeated  mus- 
cular strains,  and  intestinal,  renal,  muscular,  and  cutaneous  sluggishness 
count  for  something  in  its  causation. 

The  cerebral  symptoms  produced  by  arteriosclerosis  cover  a  wide 
range,  but  are  all  due  to  faults  of  brain-nutrition.  They  embrace  those 
of  senility,  premature  senility,  and  degenerative  processes,  both  chronic 
and  acute.  The  highest  and  most  delicate  brain-functions  are  likely  to 
be  first  affected.  We,  therefore,  find  lessened  mentality,  aphasia,  and 
monoplegias  or  mere  clumsiness  of  the  hands.  Paresthesias  are  very 
common.    Hemiplegic  and  diplegic  manifestations  are  observed.    At  first 


ARTERIAL    BRAIN  DISEASES.  199 

these  symptoms  are  temporary  and  recurrent,  but  unless  the  arterial 
condition  improves,  they  tend  to  become  more  and  more  continuous 
and  permanent.  Slight  attacks  of  hebetude  or  sleepiness  may  eventuate 
in  stupor,  coma,  and  even  in  death.  Jacksonian  and  generalized  con- 
vulsions, syncopic  attacks,  and  periods  of  mental  confusion  are  all  within 
the  range  of  this  protean  malady.  If  the  fibroid  change  occludes  a 
cerebral  vessel,  it  acts  like  a  thrombus,  to  which,  indeed,  it  often  leads, 
and  a  softened  infarct  results  in  permanent  loss  of  localized  brain- 
function.  Many  islands  of  softening  and  many  sclerotic  patches  may 
be  due  to  this  cause  and  present  multiple  symptoms.  Diffuse  sclerotic 
processes  in  the  cortex  are  associated  with  it,  and  it  underlies  some 
of  the  cerebral  lesions  of  general  paresis  and  tabes.  Associated  minor 
symptoms,  such  as  vertigo,  headache,  insomnia,  irritability,  lack  of  mental 
energy  and  muscular  force,  and  the  craving  for  stimulants,  all  point  to 
the  lowered  nutrition  of  the  brain.  All  the  manifestations  of  cerebral 
arteriosclerosis  are  likely  to  come  at  first  in  gusts  and  waves. 

Symptoms. — The  physical  examination  of  a  case  of  arteriosclerosis 
usually  demonstrates  a  tortuous,  rigid,  frontal  artery,  sometimes  moving 
under  the  skin  in  a  vermicular  manner  at  each  pulse-wave.  The  cornea 
commonly  is  the  seat  of  a  marked  senile  arcus.  The  radials,  brachials, 
femorals,  and  all  palpable  arterial  trunks  are  tense  and  rigid.  The  pulse 
is  one  of  high  tension.  A  light  finger  imperfectly  detects  it,  but  it  seems 
to  increase  as  pressure  is  applied  and  can  hardly  be  obliterated.  There  is 
usually  an  enlarged,  laboring  heart,  and  often  roughened  valvular  sounds. 
The  urine  is  likely  to  show  albumin  and  the  formed  elements  that  mark 
chronic  nephritis.  Often  the  quantity  of  urea  is  scantv^  or  markedly 
deficient,  A  constipated  habit  is  the  rule,  and  the  general  health  is 
below  par.  In  less  advanced  cases  the  general  indications  of  the  arterial 
state  may  be  very  slight  and  yet  the  cerebral  mischief  may  be  extensive. 
This  is  especially  true  in  the  sypliilitic  varieties.  The  same  processes 
that  take  place  in  cerebral  structures  affect  the  cord,  and  mav,  and  often 
do,  give  rise  to  organic  mischief,  furnishing  the  basis  of  many  systema- 
tized and  unsystematized  cord-lesions. 

The  treatment  of  arteriosclerosis  affecting  the  brain  must  be  under- 
taken at  an  early  stage  if  much  is  to  be  accomplished.  Toxic  causes,  if 
present,  must  be  eliminated.  Syphilis,  gout,  lead  poisoning,  alcohol- 
ism, renal,  pulmonary,  and  cardiac  conditions  must  receive  their 
appropriate  management.  The  arterial  spasm  due  to  the  local  irri- 
tation of  the  muscular  tunic,  and  perhaps  also  to  uric  products  in 
the  circulation,  must  be  overcome.  To  relieve  the  spasm  the  nitrites, 
especially  nitroglycerin,  may  be  given  at  short  intervals.  Mercurials 
and  much  drinking  water  to  cleanse  the  intestines  and  stimulate  the 
kidneys  are  valuable  aids.  Alkaline  waters  such  as  Vichy  and  the  lithia 
waters  are  good.  Care  of  the  digestive  tract  and  of  the  diet  is  of  the  first 
importance.  All  excesses  must  cease.  A  simple,  easily  digested  regimen, 
with  a  very  limited  amount  of  red  meats,  starches,  and  sugars,  should 
be  ordered.  The  skin  should  be  kept  active  by  baths,  frictions,  and 
massage.  If  muscular  exercises  are  for  any  reason  contraindicated  or 
Jiot  available,  massage  may  take  their  place.     An  outdoor  habit  should 


200  DISEASES  OF  THE  BRAIN  PROPER. 

be  cultivated,  and  change  of  scene  may  do  much  to  reduce  the  mental 
distress  and  vague  broodings.  Of  all  medicine  directed  toward  improv- 
ing the  arterial  condition  the  iodids  easily  hold  first  rank,  but  it  should 
be  remembered  that  the  potassium  salts  depress  the  heart's  action  and 
perhaps  add  to  the  arterial  sluggishness.  Sodium  iodid  is  much  to  be 
preferred  and  is  usually  better  tolerated.  This  should  be  given  in  doses 
of  from  five  to  twenty  grains  after  meals,  and  continued  for  months  and 
years,  with  short  intervals.  A  good  plan  is  to  order  the  iodid  discon- 
tinued during  every  fifth  week.  Tonics  are  almost  invariably  required. 
Arsenic  can  be  readily  given  Avith  the  iodid,  and  strychnin  is  perhaps 
the  best  aid  to  the  laboring  heart.  Avoid  digitalis  and  everything  else 
that  tends  to  increase  arterial  tension.  No  harm  seems  to  come  from  the 
frequent  use  of  amyl  nitrite  or  trinitrin,  and  the  prompt,  though  tran- 
sient, relief  produced  is  often  very  gratifying,  besides  in  a  way  confirm- 
ing the  diagnosis. 

Under  such  a  plan  of  treatment,  aphasias,  mental  disturbance,  hemi- 
paresis,  and  many  other  symptoms  of  brain  disturbance  will  sometimes 
rapidly  clear  up  and,  if  not  cured,  remain  in  abeyance  for  years,  pro- 
vided moderation  in  all  things  be  the  rule  of  life.  The  prognosis, 
however,  should  be  guarded,  as  we  know  that  brain-cells  degenerate 
beyond  recovery  if  entirely  deprived  of  their  blood-supply  for  about 
forty-eight  or,  at  the  most,  seventy-two  hours  at  a  time.  At  best  it  is 
evident  that  the  presence  of  arteriosclerosis  signifies  a  shortened  life-lease. 

Syphilitic  Arteritis. — It  is  now  generally  recognized  that  cere- 
bral arteritis  from  syphilitic  infection  may  be  a  comparatively  early 
manifestation  of  the  disease.  Ogilvie  shows  from  Naunyn's  statistics 
that  syphilitic  diseases  of  the  cerebrospinal  axis  present  the  greatest  pro- 
portion of  cases  during  the  first  year  following  the  initial  lesion,  but  they 
may  appear  even  after  a  score  of  years.  The  basilar,  carotids,  circle 
of  AVillis,  and  large  cerebral  arteries  are  those  usually  implicated,  but 
smaller  brain-arteries  may  be  similarly  diseased.  The  specific  inflam- 
mation may  produce  a  peri-arteritis  and  nodular  plaques  that  look  some- 
thing like  those  of  atheroma,  or  it  may  invade  and  infiltrate  all  the 
arterial  walls  with  gummy  products,  commencing  either  as  an  endarter- 
itis or  a  peri-arteritis.  Long-standing  syphilitic  arteritis,  especially  of  the 
large  vessels  of  the  base,  produces  a  sclerous  degeneration  that  does  not 
calcify.  It  is  generally  circumscribed  in  small  patches,  causing  bulging 
of  the  internal  and  external  coats,  deforming  the  artery  and  altering  its 
capacit}^ 

Syphilitic  arteritis  leads  to  :  (1)  Obstruction  of  the  vessel  by  the  pro- 
duction of  thrombosis  or  by  an  obliterating  endarteritis ;  (2)  rupture 
and  hemorrhage,  and  (3)  aneurysm.  It  may  appear  at  any  age  and 
may  follow  inherited  syphilis  in  children  and  even  in  adults. 

The  most  prominent  indications  of  syphilitic  disease  of  the  cerebral 
arteries  are  the  prodromata.  Of  these  the  syphilitic  headache,  coming  on 
usually  toward  evening  and  lasting  until  midnight,  is  the  most  distinct- 
ive. Except  that  due  to  tumor,  it  is  the  most  intense  and  unmanage- 
able headache  with  which  the  physician  is  called  upon  to  deal.  Or- 
dinarily it  is  not  confined  to  any  portion  of  the  head,  but  is  described  as 


CEREBRAL   HEMORRHAGE  AND    THE  HEMIPLEGIC  STATE.       201 

being  somewhat  superficial,  unlike  the  deep-seated  pain  of  tumor.  Un- 
less the  condition  is  now  recognized  or,  as  is  rarely  the  case,  sponta- 
neously subsides,  disturbances  in  the  cortex  are  likely  to  appear,  marked 
by  paresthesias  and  loss  of  power  in  the  extremities  or  disturbance  of 
speech  and  the  special  senses.  After  vacillating  symptoms  of  this 
character,  which  have  a  tendency  to  recur  at  intervals  of  a  few  davs 
or  weeks,  an  apoplectic  stroke,  due  to  sudden  rupture  of  the  vessel, 
may  ensue,  or  a  complete  thrombosis  lead  to  cerebral  softening.  When 
hemorrhage  or  thrombosis  takes  place  the  headache  usually  disappears, 
or  sometimes  it  disappears  a  few  days  before  the  onset  of  serious  results. 
The  symptoms  are  those  of  cortical  irritation  and  the  eventual  onset  of 
paralysis  is  usually  not  marked  by  complete  loss  of  consciousness,  ex- 
cept in  the  hemorrhagic  form,  and  coma  is  the  great  exception.  Apha- 
sia, facial  paralysis,  monoplegia,  paresthetic  tingiings,  preceded  bv  a  his- 
tory of  violent  headache,  with  nocturnal  exacerbations,  strono-lv  indicate 
syphilitic  disease  of  the  cerebral  arteries,  even  in  the  absence  of  anv  his- 
tory of  specific  infection.  As  has  been  shown  by  Charcot,  almost  invari- 
ably there  is  some  degree  of  basilar  syphilitic  meningitis  in  these  cases 
and  transient  or  permanent  disturbance  of  the  ocular  apparatus  is  often 
added. 

According  to  Charrier  and  Klippel,  the  cliief  groups  of  cerebral  mani- 
festations of  syphilitic  disease  of  the  arteries  are :  (1)  Apoplexy ; 
(2)  paralysis  from  obliterating  arterial  disease  ;  (3)  slight  aphasia  and 
transitory  varying  palsies,  and  (4)  intellectual  disturbance  somewhat 
similar  to  that  of  general  paresis.  There  is  also  reason  to  suppose  that 
it  is  the  true  though  remote  basis  of  general  paresis. 

The  treatment  of  the  condition  should  be  energetic  even  when  it  is 
diagnosed  early,  and  will  be  discussed  at  length  under  the  consideration 
of  General  Syphilitic  Diseases  of  the  Xervous  System. 

Acute  arterial  degenerations  of  an  amyloid  and  fatty  character 
aflPecting  the  cerebral  vessels  may  follow  munerous  states  marked  by 
various  systemic  infections.  Only  in  very  rare  instances  do  thev  give 
rise  to  marked  cerebral  symptoms,  and  these  are  usuallv  overshadowed 
by  the  general  state.  Rupture  and  hemorrhage  or  thrombosis  and 
softening  may  be  due  to  them. 


CHAPTER  VI. 

CEREBRAL  HEMORRHAGE  AND  THE  HEMIPLEGIC 

STATE. 

Excepting  traumatic  cases,  hemorrhage  into  the  substance  of  the 
brain  is  a  secondary  or  terminal  eifect  of  degenerative  or  inflamma- 
tory disease  of  the  cerebral  blood-vessels,  almost  invariablv  of  the 
arteries.  Usually  of  comparatively  slight  seriousness  in  itself,  the  re- 
sulting injury  or  destruction  of  important  brain-structures  entails  per- 
manent disability  if   an    early  fatality   is    escaped.     All  parts  of  the 


202  DISEASES   OF  THE  BRAIN  PROPER. 

encephalon  are  subject  to  arterial  disease  and  resulting  hemorrhage,  but 
certain  locations  present  special  liabilities.  The  most  frequent  site  is  in 
the  distribution  of  the  lenticulostriate  arteries  arising  directly  from  the 
trunk  of  the  middle  cerebral  and  supplying  the  basal  ganglia  and  their 
internal  and  external  capsules.  Of  these,  the  anterior  branch  is  the 
so-called  artery  of  cerebral  hemorrhage.  After  the  region  of  the  basal 
ganglia  and  capsules,  in  order  of  frequency  as  sites  of  cerebral  hemor- 
rhage, follow  the  centrum  ovale,  cortex,  cerebellum,  pons,  medulla,  crura, 
and  corpus  callosum.  So  commonly,  however,  does  hemorrhage  occur 
in  the  neighborhood  of  the  large  ganglia  that  a  somewhat  definite  clini- 
cal type  of  cerebral  hemorrhage  is  presented.  This  will  first  engage 
our  attention,  and  then  the  less  frequent  sorts  and  varieties,  all  of  which 
have  symptoms  in  common,  may  be  rapidly  sketched. 

Pathological  Anatomy. — Cerebral  hemorrhage  of  the  capsular 
variety  occurs  with  about  equal  frequency  on  the  two  sides  of  the  brain. 
The  quantity  of  blood  extravasated  depends  upon  two  factors,  (1)  the 
size  of  the  blood-vessel  and  (2)  the  arterial  pressure,  but  the  pres- 
sure is  much  the  more  important  of  the  two.  According  to  Wernicke 
"the  apoplectic  or  traumatic  effect  is  equal  to  the  product  of  the 
amount  of  eifused  blood  into  the  square  of  the  pressure  with  which 
it  is  extravasated."  Ordinarily  the  hemorrhage  commences  in  the  an- 
terior portion  of  the  lenticular  nucleus  and  separates  or  tears  through 
the  adjoining  structures,  invading  the  internal  capsule,  the  external  cap- 
sule, and  the  optic  thalamus.  It  may  extend  upward  into  the  centrum 
ovale  or  tear  into  the  lateral  ventricle,  and  finally  break  through  into 
the  pial  spaces  at  the  base  near  the  optic  chiasm.  Very  exceptionally 
the  blood  breaks  through  the  cortex  of  the  convexity,  but  ordinarily  it 
is  arrested  at  the  lower  surface  of  the  gray  matter. 

Recent  hemorrhages  show  a  coagulum  bathed  in  serum  and  non- 
adherent to  the  surface  of  the  hemorrhagic  pocket.  After  a  few  days 
the  serum  is  relatively  increased,  the  coagulum  is  contracted,  and  is 
attached  to  the  adjoining  structures  by  fibrinous  trabeculse.  Absorption 
of  the  serum  then  follows.  The  clot  is  resorbed  in  part,  and  finally 
only  an  ocherous  mass  remains,  made  up  of  blood-crystals,  pigment, 
and  fatty  detritus.  By  thickening  and  participation  of  the  surrounding- 
brain  a  sort  of  cyst  is  formed.  If  it  is  small  and  its  walls  coapt, 
cicatrization  may  ensue.  About  large  so-called  apoplectic  cysts  there  is 
usually  a  zone  of  degeneration  and  fatty  softening.  This  is  often  the 
seat  of  minute  hemorrhages,  and  is  likely  to  undergo  inflammatory 
changes  or  by  infection  become  purulent.  An  abscess  thus  results  in 
which,  sometimes,  the  partially  organized  hemorrhagic  clot  floats. 

Even  in  recent  hemorrhages  there  is  difficulty  in  determining  the 
origin  of  the  blood.  By  carefully  washing  away  the  clot  under  water 
miliary  aneurysms  are  almost  certain  to  l)e  found.  They  bead  the 
arterial  vessels  that  are  brought  to  light,  and  sometimes  one  is  fortunate 
enough  to  find  the  minute  sac  originally  ruptured  and  still  containing 
a  fragment  of  organized  clot.  Other  vascular  lesions  that  occasionally 
give  rise  to  cerebral  hemorrhage  are  amyloid,  hyaline,  syphilitic,  and  fatty 
arterial  degenerations  and  acute   infective  arteritis.      In  ancient  cases 


CEREBRAL  HEMORRHAGE  AND    THE  HEMIPLEGIC  STATE.        203 

cicatrization   and   spreading  degenerative   changes  usually   obscure  the 
exact  vascular  fault. 

The  motor  tracts  that  are  cut  by  the  lesion  present  a  descending  de- 
generation whicli  extends  downward  the  whole  length  of  the  neuron.  In 
the  cord  the  pyramidal  tracts  are  usually  both  involved,  but  to  a  greater 
extent  on  the  side  opposite  the  lesion.  Exceptionally  in  cases  of  long 
standing,  changes  in  the  upper  motor  tract  entail  secondary  disturbance 
on  the  lower  motor  and  trophic  neuron,  and  an  amyotrophic  condition 
is  superadded,  with  corresponding  degeneration  in  the  anterior  horns. 

Etiology. — In  any  given  case  of  cerebral  hemorrhage  there  are, 
ordinarily,  a  number  of  causative  elements.  Almost  invariably  there  are 
(1)  liic/h  arterial  tension  and  (2)  lowered  arterial  resistance.  The  causes 
of  miliary  aneurysm  are  much  the  same  as  those  of  rigid  arteries, 
atheroma,  and  cardiac  hypertrophy.  The  strongly  acting  heart  drives 
the  blood-column  through  the  rigid  aorta  and  carotid,  and  its  full  force 
falls  upon  the  arteries  arising  from  the  circle  of  Willis.  These  are 
of  comparatively  small  caliber,  and,  not  having  outlets  by  anastomosis, 
oppose  a  dead  wall  of  resistance  to  the  directly  received  cardiac  impulse. 
Surrounded  in  turn  by  perivascular  spaces  and  not  supported  by  firm 
parenchymatous  tissues,  their  walls  weakened  by  age  or  infection  and 
yielding  at  numerous  points  to  the  formation  of  saccular  dilatations, 
arterial  rupture  naturally  follows. 

The  predisposing-  causes  of  cerebral  hemorrhage  are  those  that  pro- 
duce or  tend  to  produce  the  primal  arterial  disease.  Advanced  age, 
gout,  alcoholism,  rheumatism,  plumbism,  and  syphilis  are  chronic  states 
favoring  it.  Acute  infections,  tending  to  produce  acute  arteritis  or 
amyloid  and  fatty  degenerations,  such  as  puerperal  infection,  diphtheria, 
scarlet  fever,  etc.,  are  possible  active  factors.  Whooping-cough  in  chil- 
dren is  an  occasional  cause,  the  factors  of  strain,  infection  and  lowered 
resistance  all  being  present.  4n  undoubted  hereditary  tendency  to 
cerebral  hemorrhage  is  sometimes  encountered.  The  writer  is  familiar 
with  one  family  of  eleven  brothers  and  sisters,  nine  of  whom  have 
died  from  cerebral  apoplexy.  The  so-called  apoplectic  habit  has  no 
significance  if  not  associated  with  other  predisposing  conditions.  The 
relation  of  age  to  cerebral  hemorrhage  is  an  important  one.  During 
the  first  year  of  life  it  is  relatively  frequent,  and  drops  -thence  to  the  end 
of  the  first  decade.  Gowers  states  that  a  proportion  of  1.8  to  every  1000 
under  the  age  of  ten  have  suifered  from  this  accident.  From  ten  to 
twenty-five  it  is  infrequent,  and  then  rapidly  mounts,  reaching  its  maxi- 
mum at  about  fifty-five,  thence  again  descending,  and  seldom  occurs  after 
seventy-five  years  of  age.  The  male  sex  shows  considerable  preponder- 
ance, about  three  males  to  two  females  suffering  from  cerebral  hemor- 
rhage. This  is  due  to  their  greater  tendency  to  excesses  and  increased 
liability  to  exposures.  Temperate  climates  and  winter  months  show  an 
excess  of  cases  over  the  opposite  conditions. 

Everything  which  induces  an  accelerated  circulation  must  be  ranked 
as  an  inciting-  cause.  All  physical,  mental,  and  moral  shocks,  and 
all  intense  emotions  may  lead  to  cerebral  apoplexy  in  those  predisposed. 
Muscular    efforts,   coughing,   sneezing,    straining    at    stool,    coitus,   and 


204  DISEASES  OF  THE  BRAIN  PROPER. 

vomiting  have  induced  it.  Derangements  of  the  circulation  with  cardiac 
effort,  due  to  exposure  to  the  cold  or  from  a  cold  bath  or  a  bath  after  a 
full  meal,  have  served  to  rupture  the  diseased  artery.  In  the  Great  Lake 
region  of  this  country  the  frequent  sudden  changes  in  barometric  pressure, 
attended  as  they  very  often  are  by  extraordinary  variations  in  atmos- 
pheric humidity  and  temperature,  constitute  a  menace,  if  they  do  not 
furnish  an  inciting  cause  of  cerebral  hemorrhage.  It  often  follows  a 
debauch. 

Symptoms. — The  onset  of  cerebral  hemorrhage  of  the  capsular 
variet}"  is  almost  invariably  abrupt,  and  constitutes  the  type  of  cerebral 
apoplexy  that  is  familiarly  and  properly  called  "a  stroke."  In  very 
exceptional  cases  it  is  preceded  by  momentary  confusion,  vertigo,  un- 
easiness, or  other  vague  subjective  disturbance.  Most  of  the  alleged 
prodromata  are  merely  symptomatic  of  the  arterial  condition  that  always 
precedes  the  stroke,  and  are  common  to  peri-arteritis  and  arteriosclerosis. 
A  hypertroj)hied  heart,  rigid  artery,  and  high  arterial  tension,  a  con- 
tracted kidney  and  albuminuria,  with  or  without  formed  kidney  ele- 
ments, are  of  some  value  in  presaging  an  apoplectic  seizure  from 
cerebral  hemorrhage.  The  patient,  ordinarily,  is  stricken  down, 
and  in  the  foudroyant  cases  may  die  instantly.  If  walking,  he  falls 
heavily,  or  if  sitting,  reels  out  of  his  chair.  Consciousness  is  almost 
instantly  abolished.  The  action  of  any  of  the  inciting  causes  named 
above  will  correspondingly  affect  the  opening  scene.  At  first  the  face 
is  pale,  the  pupils  contracted,  and  muscular  twitchings  or,  rarely,  active 
general  convulsions  may  occur. 

In  the  apoplectic  state  that  follows  the  patient  lies  inert,  uncon- 
scious, breathing  slowly  and  stertorously,  and  often  presenting  the 
Cheyne-Stokes  respiration.  The  face  is  mottled  or  even  deeply  con- 
gested, covered  with  perspiration,  and  expressionless.  The  half-open 
eyes  present  sluggish  or  inactive  and  usually  contracted  pupils.  The 
conjunctiva  is  usually  congested  and  insensible,  and  the  palpebral  reflex 
is  wanting.  All  forms  of  sensibility  are  abolished.  The  sphincters  are 
relaxed  and  the  limbs  limp.  There  is  usually  urinary  retention,  and 
ovei'flow  occurs  later.  At  this  time  it  may  be  difficult  to  determine 
which  hemisphere  has  been  injured.  Sometimes,  by  careful  examina- 
tion, the  paralyzed  side  is  found  more  completely  relaxed  than  the  other, 
in  which,  perhaps,  some  slight  resistance  to  passive  movements  is  present, 
or  the  sound  limbs  when  raised  do  not  fall  so  heavily.  There  is  also, 
even  from  the  first,  a  tendency  for  the  patient  to  direct  his  face  and  eyes 
in  conjugate  deviation  to  the  side  of  the  brain  that  contains  the  hemor- 
rhage. This  indicates  muscular  paralysis  on  the  side  from  which  they 
are  turned.  This  deviation  must  not  be  of  the  spasmodic  sort,  which  has 
an  opposite  significance.  At  first  all  the  cutaneous  and  muscle  reflexes 
are  temporarily  increased,  but  immediately  subside  and  tend  to  dis- 
appear. Sometimes  they  show  most  diminution  on  the  paralyzed  side. 
The  comatose  condition  either  deepens  into  death  or  passes  off. 

After  a  variable  period  of  hours  or  even  days  the  coma,  in  cases  not 
immediately  fatal,  gradually  yields  to  torpor,  in  which  the  patient  can 
be  roused  by  strong  and  especially  by  painful  stimulation.     He  pushes 


CEREBRAL    HEMORRHAGE  AND    THE  HEMIPLEGIC  STATE.       205 

away  the  pinching  fingers  of  the  examiner,  mutters  a  little,  takes  a 
deep,  quick  inspiration,  or  otherwise  manifests  discomfort.  Then  he 
hears  loud  voice-sounds,  and  finally  shows,  by  facial  expression  and 
attempts  at  speech,  that  he  has  regained  partial  consciousness.  If  undis- 
turbed, he  relapses  into  stertorous  sleep,  and  the  expired  air  pufi^s  out  the 
flabby  cheek  of  the  paralyzed  side  of  the  face  and  escapes  through  the 
angle  of  the  mouth  on  that  side.      Finally  consciousness  is  restored. 

vShortly  after  the  stroke  the  rectal  temperature  is  slightly  lowered,  but 
is  likely  to  rise  a  little  above  normal  after  a  day  or  two.  In  all  cases 
after  a  few  hours  the  temperature  will  be  found  higher  on  the  side  from 
which  the  eyes  are  averted — that  is,  on  the  paralyzed  side — than  on  the 
other.  This  is  true  of  the  face,  trunk,  and  extremities,  and  the  dif- 
ference amounts  to  from  1°  to  2°  F.  At  the  same  time  this  warmer, 
paralyzed  side  often  shows  increased  perspiration,  and  usually  an  in- 
tensified redness  and  congestion  as  compared  with  the  other. 

The  motor  loss  in  this  variety  of  cerebral  hemorrhage  is  hemiplegic. 
After  consciousness   has  partly  returned  its  distribution  can  be  plainly 


Fig.  85. — Right  heniiparesis  with  athetosis  in  hand.     1,  Ordinary  expression  ;  2,  spasmodic  involuntary 
laughter,  showing  hilateral  action  of  facial  muscles. 


determined.  Usually  the  arm  is  much  more  affected  than  the  leg,  and 
the  face  shows  great  variations  of  implication  in  different  cases.  In  some 
it  is  scarcely  affected.  As  a  rule,  the  distal  portion  of  the  limb  is  much 
more  affected  than  the  portion  near  the  trunk.  The  hand  thus  suffers 
proportionately  more  than  the  arm  or  shoulder,  the  foot  than  the  thigh. 
The  muscles  of  the  trunk,  being  paired  and  fully  represented  bilaterally 
in  the  cortex,  do  not  show  much  one-sided  loss  of  power.  A  careful 
examination  will,  however,  detect  reduced  respiratory  excursions  on  the 
palsied  side  and  unilateral  weakness  in  the  acts  of  sneezing,  coughing,  etc.  ^ 
The  facial  asymmetry  offers  several  important  and  significant  peculiarities. 
Except  in  the  rarest  instances  it  is  only  the  lower  half  of  the  facial- 
nerve  distribution  tliat  is  much  impaired.  The  frontal  and  orbicular 
regions  show  but  little  lack  of  power ;  the  brows  are  raised,  the  eyes 
close  and  open  nearly  as  well  as  ever,  but  a  slight  unilateral  paretic 
defect  is  certainly  present  as  a  rule.  In  the  lower  face  the  lack 
of  muscular  power  and  tone  allows  the  mouth,  chin,  and  even  the 
nose  to  deviate  to  the  sound  side.  All  voluntary  attempts  to  use 
^Sicard,  "Arch,  de  Neurolog. , "  Dec,  1899. 


206  DISEASES  OF  THE  BRAIN  PROPER. 

the  labial,  nasal,  and  zygomatic  muscles  increase  the  deformity,  but 
usually  in  emotional  expression,  as  in  laughing  or  weeping,  the  lack 
of  symmetry  tends  to  disappear  (Fig.  85).  Only  when  the  basal 
ganglia,  and  particularly  the  thalamus,  are  seriously  invaded  by  the 
hemorrhage  do  emotional  expressions  also  intensify  the  one-sidedness. 
Even  then  the  retention  of  power  in  the  upper  half  of  the  face  distin- 
guishes this  palsy  from  that  of  disease  of  the  seventh  nerve.  The 
conjugate  deviation  of  head  and  eyes  passes  away  as  consciousness 
returns,  but  the  tongue  when  protruded  turns  strongly  to  the  paralyzed 
side,  OAving  to  the  weakness  in  the  corresponding  genioglossus.  AVith 
the  tongue  protruded  the  patient  can  not  move  its  tip  across  the  median 
line  toward  the  sound  side.  This  lack  of  muscular  power  in  the  tongue 
and  lips  tends  to  muffle  and  thicken  the  speech,  which  may  even  become 
nasal,  as  the  soft  palate  shares  in  the  muscular  weakening  and  droops 
on  the  paralyzed  side.  Apjhasia  is  not  ordinarily  produced  by  capsular 
hemorrhage.  In  exceptional  cases  the  lesion  implicates  the  cortico- 
peduncular  speech-tracts,  producing  a  variety  of  motor  aphasia  marked 
largely  by  ataxic  control  of  the  muscles  of  speech-production. 

Sensory  Disturbances. — As  consciousness  return^  after  the  stroke, 
ordinarily  the  complete  cutaneous  insensibility  disappears.  Only  in 
those  cases  in  which  the  lesion  destroys  the  sensory  pathway  in  the  jdos- 
terior  third  of  the  posterior  limb  of  the  capsule  do  we  have  persistent 
hemianesthesia  corresponding  to  the  hemiplegia.  This  identical  anesthetic 
field  is  sometimes  encountered  in  hysteria,  which  may  indeed  be  induced 
by  the  shock  of  a  cerebral  hemorrhage  as  well  as  by  any  other  accident, 
and  may  give  rise  to  a  perplexing  combination.  Close  scrutiny  for 
other  evidence  of  antecedent  hysteria  should  be  made  in  all  such  cases. 
The  sensory  disturbance  in  the  limbs  is  usually  more  pronounced  toward 
their  distal  extremities,  where  the  paralysis  is  also  always  most  marked 
and  persistent.  Hemianopsia  is  frequently  present  immediately  after  the 
stroke,  but  usually  passes  away  in  a  few  days  with  the  other  sensory 
disturbances.  When  the  visual  path  at  the  sensory  crossway  is  injured, 
hemianopsia  persists.  Even  when  the  patient  is  still  inclined  to  stupor  it 
may  be  detected  by  bringing  the  fingers  into  the  visual  field  first  from  one 
and  then  from  the  opposite  side.  Disturbance  of  other  special  senses  is  sub- 
ject to  the  same  rule.  Often  there  is  considerable  pain  and  sensitiveness 
in  the  paralyzed  limbs.  Severe  headaches  and  vertigo  are  uncommon 
until  the  hemiplegic  state  is  established,  and  even  then  they  are  rare. 

Trophic  disturbance  in  the  early  days  after  cerebral  hemorrhage  is 
rare.  An  acute  bedsore  sometimes  appears  over  the  buttock  of  the 
paralyzed  side,  and  in  a  few  days,  almost  in  a  few  hours,  attains  large 
dimensions.  Such  cases  almost  invariably  soon  terminate  in  death. 
Rapid  emaciation  and  even  rapid  fattening  are  encountered  at  times. 
Disturbance  of  the  medullary  nuclei  probably  accounts  for  temporary 
albuminuria  and  glycosuria,  A^'hich  are  incidentally  observed  in  some 
cases.  To  the  same  source  some  attribute  the  rare  gastric  and  intestinal 
hemorrhages.  Occasionally  a  large  joint  on  the  palsied  side,  notably  the 
shoulder,  may  develop  an  acute  arthritis,  and  all  the  articulations  of  the 
paralyzed  limbs  are  later  on  inclined  to  rigidity  out  of  proportion  to 


CEREBRAL   HEMORRHAGE  AND    THE  HEMIPLEGIC  STATE.       207 

their  disuse.  After  the  first  week  a  rapid  elevation  of  temperature  is 
sometimes  produced  by  the  development  of  an  infectious  cerebritis  about 
the  hemorrhagic  focus.      It  usually  ends  fatally. 

The  hemiplegic  state  finds  its  prototype  in  the  cases  that  survive 
the  stroke  of  cerebral  hemorrhage.  It  must  not  be  overlooked  that 
it  is  a  sequence  common  to  many  cerebral  and  spinal  lesions,  and  is 
associated  with  some  neuroses.  It  may  follow  :  (1)  Traumatic  lesions 
of  the  brain  and  cord  ;  (2)  meningeal  lesions  due  to  hemorrhage,  inflam- 
mation, syphilis,  and  tuberculosis ;  (3)  cerebral  lesions  due  to  hemor- 
rhage, softening,  tumors,  abscesses,  and  sclerosis ;  (4)  cerebrospinal 
lesions  of  tabes,  multiple  sclerosis,  and  general  paralysis  of  the  insane. 
It  may  be  due  originally  to  :  (1)  Intoxication  by  uremia,  diabetes, 
alcohol,  lead,  mercury,  and  some  carbon  compounds ;  (2)  infections  from 
pneumonia,  malaria,  typhoid  fever,  puerperal  fever,  eruptive  fevers, 
diphtheria,  influenza,  syphilis,  and  tuberculosis ;  (3)  it  marks  some 
cases  of  chorea,  hysteria,  and  paralysis  agitans. 

In  cerebral  hemorrhage,  if  death  does  not  occur  during  the  first  three 
weeks,  improvement  in  the  paralytic  features  uniformly  appears  and 
is  progressive  for  several  months.  Finally,  all  gradations  are  encoun- 
tered, from  the  slightest  paresis  to  complete  hemiparalysis.  In  a  well- 
marked  case,  in  which  at  first  the  hemiplegia  is  complete,  we  may  ex- 
pect some  return  of  voluntary  motion  after  ten  or  fifteen  days.  The 
lower  extremity  first  shows  improvement,  and  is  followed  by  the  face  and 
later  by  the  upper  extremity.  In  six  to  eight  weeks  the  patient  may 
stand  and  perhaps  with  much  aid  walk  a  little.  During  this  time  a  not- 
able change  has  appeared  in  the  reflexes  and  the  tone  of  the  paralyzed 
muscles  is  greatly  altered.  At  first  the  reflexes  are  abolished  or  greatly 
diminished  and  the  muscles  hang  limp  and  flabby  from  the  bones.  Grad- 
ually the  reflexes  increase  and  become  exaggerated.  Transient  stiffness 
and  rigidity  are  then  found  in  the  limbs.  Ankle-clonus,  rectus-clonus, 
and  even  wrist-clonus  appear,  and  with  the  temporary  rigidities  fore- 
shadow the  later  contractures.  The  increase  in  myotatic  irritability  may 
be  expected  to  appear  during  the  third  week,  and  is  always  present  sooner 
or  later,  if  the  motor  pathway  in  the  brain  is  injured  by  the  hemorrhage. 

Introduced  by  the  myotatic  irritability,  clonus,  and  the  fleeting  attacks 
of  rigidity,  the  period  of  late  contractures  is  established  from  one  to  four 
months  after  the  stroke.  In  very  rare  cases  it  is  never  fully  developed, 
and  in  other  rare  cases,  owing  to  secondary  changes  in  the  trophic  cen- 
ters of  the  cord,  it  disappears  after  being  well  marked  for  years  and 
muscular  atrophy  develops,  but  the  rule  is  that  once  present  it  is  pro- 
gressive for  a  time  and  then  permanently  remains.  Under  the  action 
of  this  contracture  the  limbs  assume  characteristic  rigid  attitudes  that 
constitute  great  deformities.  It  sometimes  strongly  involves  the  face, 
which  is  then  drawn  to  the  affected  side  and  gives  to  the  sound  side  a 
false  appearance  of  weakness. 

In  the  upper  extremity  the  flexors  predominate  to  draw  the  digits 
into  the  palm  of  the  hand,  to  flex  the  wrist,  to  pronate  the  forearm, 
and  to  fix  the  elbow  at  an  angle.  The  extremity  is  usually  held  close 
to  the  chest.      In  these  vicious   positions  the  joints  become  practically 


208 


DISEASES  OF  THE  BRAIN  PROPER. 


soldered.  After  the  case  is  somewhat  chronic,  if  the  fingers  or  wrist 
are  extended,  they  fairly  snap  back  to  their  flexed  positions,  and  the 
tightly  clenched  fingers  may  cause  trophic  lesions  in  the  palm.  In  cases 
of  long  standing,  probably  both  from  the  enforced  inactivity  and  trophic 
disturbance,  the  range  of  joint  movements  is  considerably  limited  irre- 
spective of  the  muscular  contracture,  and  sometimes  this  appears  early. 


Fig.  86. — Contractured  positions  in  hemiplegic  hand- 
In  the  loicei^  extremity  extension  prevails.  The  knee  is  held  quite  rigidly 
extended  and  there  is  a  tendency  to  equinovarus,  so  that  the  foot  rolls 
over  on  its  outer  border.  These  are  the  usual  contractures,  and  give  to 
the  patient  an  attitude  and  a  gait  that  are  distinctive.  It  will  be  re- 
called that  the  distal  portions  of  the  extremities  are  most  aifected,  and 


Fig.  87.-' 


The  hemiplegic  gait.     1  and  2,  Advancing  the  hemiplegic  leg  in  a  circle  from  the  hip ;  3,  bear- 
ing weight  on  paretic  leg  and  cane  while  advancing  sound  limb. 


now,  rigidly  fixed  by  the  contractures,  they  are  moved  en  masse  by  the 
muscles  of  the  pelvic  and  shoulder  girdles.  In  walking  the  rigid  lower 
extremity  is  used  somewhat  as  a  peg-leg.  The  body-weight  is  carried  on 
the  sound  limlj,  over  whicli  the  trunk  inclines  outwardly,  and  by  body  and 
pelvic  movements  the  paretic  lower  limb  is  swung  forward,  the  drag- 
ging toe  describing  an  arc-like  course  around  the  heel  of  the  sound  side. 


CEREBRAL  HE3WRRHAGE  AND   THE  HEMIPLEGIC  STATE.       209 

Then  upon  the  paralyzed  limb,  often  trembling  with  clonic  action,  as 
upon  a  stilt,  the  next  step  is  taken  by  the  sound  side,  aided  usually  by 
a  cane  or  crutch. 

A  marked  minority  of  cases  show  a  type  of  extension  in  the  upper 
extremity,  which  is  most  pronounced  at  the  elbow.  The  limb  is  held 
rigidly  by  the  side  of  the  body.  The  wrist  and  fingers  may,  though 
very  rarely,  also  be  extended,  and  the  supinators  may  overbalance  the 
pronators.  Again,  flexion  may  predominate  in  the  lower  limb,  or  exten- 
sion may  be  present  in  the  upper  and  flexion  in  the  lower  limb,  or 
different  segments  of  the  same  limb  may  show  opposite  conditions  as  to 
flexion  and  extension.  This  late  rigidity  may  render  it  impossible  to 
demonstrate  the  muscle  reflexes,  which,  nevertheless,  are  greatly  exag- 
gerated. Like  the  myotatic  irritability,  the  late  contractures  are  due  to 
the  descending  degenerative  processes  in  the  motor  tracts. 

The  paralyzed  limbs  show  marked  circulatory  disturbance.  They  are 
at  first  reddened  and  cyanosed.  The  blanched  spot  caused  by  finger- 
pressure  only  slowly  disappears.  Sometimes  they  are  sodden  with  per- 
spiration and  show  epithelial  variations,  either  by  increase  or  more  often 
by  decrease  of  growth  in  the  nails,  hairs,  and  epidermis.  They  are  cold 
later  on,  and  their  temperature  is  reduced  several  degrees  as  compared 
with  the  sound  side.  At  times  there  is  marked  edema,  which  may  come 
on  very  early  in  the  case,  and  is  attributable  to  the  muscular  inactivity 
and  lymph-stasis. 

A  phenomenon  is  often  noticed  by  hemiplegics  that  gives  rise  to 
false  hope  of  returning  voluntary  movement  in  the  paralyzed  limbs. 
Sometimes  without  volition  the  paralytic  hand  may  open  or  the  leg 
draw  up.  These  movements  are  perhaps  analogous  to  the  constant 
athetoid  features  that  develop  in  some  cases.  The  entire  upper  extrem- 
ity, over  which  the  patient  has  practically  no  control,  may  execute  such 
movements  as  raising  itself  over  the  head  in  conjunction  with  the  other 
arm  in  yawning,  stretching,  or  other  instinctive  act.  These  associated 
movements  probably  result  from  the  bilaterality  of  their  cortical  represen- 
tation. Again,  if  the  hemiplegic  attempts  to  write  with  the  sound  hand, 
provided  it  is  the  one  not  formerly  used  for  that  purpose,  the  paralyzed 
hand  may  sometimes  be  seen  to  duplicate  the  motions  of  the  one  volun- 
tarily used.  Right-sided  hemiplegics  who  are  at  the  same  time  right- 
handed,  in  attempting  to  write  with  the  left  hand  sometimes  produce 
mirror  meriting,  which  is  practically  the  normal  method  for  left-handed 
individuals. 

On  the  sound  side  there  are  also  marked  disturbances.  The  reflexes 
are  exaggerated  and  even  contracture  may  develop.  The  muscular 
strength  is  reduced  from  ten  to  fifty  per  cent.  Incoordination  may  be 
pronounced. 

Complications. — The  hemiplegic  state  often  presents  sensory  com- 
plications. Subjectively  these  consist  in  paresthesias,  such  as  feelings 
of  heaviness,  dragging,  and  formication.  Sometimes  the  limbs  seem  to 
the  patient  to  be  entirely  gone.  Objectively  we  may  have  hemianes- 
thesia if  the  sensory  portion  of  the  capsule  is  injured,  and  the  other 
sensory  disturbances  of  injury  to  the  great  crossway  may  be  added. 
14 


210  DJSEA8JES  OF  THE  BRAIN  PROPER. 

A  wide  range  of  posthemiplegic  moto7'  complications  are  encountered. 
We  find  rhythmical  tremors,  as  in  hemiparalysis  agitans,  or  the  inten- 
tional variety  of  tremor,  as  in  multiple  sclerosis  of  limited  distribution. 
Irregular  movements,  like  those  of  chorea,  ataxia,  and  athetosis,  are 
quite  common  on  the  affected  side.  When  they  result  from  bilateral 
cerebral  lesions,  great  diagnostic  difficulties  are  presented.  The  pro- 
duction of  all  these  posthemiplegic  motor  symptoms  requires  that  the 
paralysis  should  not  be  complete,  and  their  presence  implies  a  condition 
of  irritation  somewhere  in  the  path  of  the  upper  motor  neuron.  This 
is  usually  furnished  by  lesions  in  the  region  of  the  basal  ganglia,  especially 
those  affecting  the  optic  thalamus  and  impinging  upon  the  capsular  fibers. 

Among  the  trophic  compjUcations,  in  addition  to  the  early,  acute  bed- 
sore, the  paralyzed  side  may  present  indolent  ulcerations  over  the 
sacrum,  elbow,  or  heel.  The  amyotrophic  disturbance  already  mentioned 
may  come  on  within  a  few  days  of  the  stroke,  or  may  appear  late  in 
the  hemiplegic  history,  and,  in  either  event,  must  be  attributed  to  inter- 
ference with  the  trophic  control  of  the  anterior  horns.  The  electrical 
reactions  then  vary  from  those  of  simple  quantitative  changes  to  the  re- 
action of  degeneration.  This  muscular  wasting  is  most  common  in  the 
upper  extremity,  and,  when  appearing  early  in  the  case,  is  of  ominous 
import. 

It  would  also  seem  that  dynamic,  if  not  actual,  changes  in  the  an- 
terior horns  must  be  accountable  for  the  occasional  acute  hypertrophic 
neuritis  that  develops  in  the  paralyzed  limbs  in  the  early  days  after  the 
illness,  and  for  the  acute  arthropathic  afections  that  also  appear  at  that 
time.  These  are  sometimes  associated.  The  diseased  joints  suggest 
rheumatism.  They  are  inflamed,  painful,  hot.  The  joint-surfaces  and 
synovial  organs  rapidly  disintegrate,  and  present  practically  the  same 
condition  as  the  arthropathies  of  tabes.  When  appearing  early  this 
joint  affection  is  of  bad  import,  like  the  acute  decubitus  and  early 
amyotrophy. 

Hemiplegia  from  the  ordinary  capsular  hemorrhage  does  not  neces- 
sarily disturb  the  7nind.  In  the  old  it  may  precipitate  the  mental  de- 
terioration of  senility,  and  it  may  be  followed  by  organic  dementia. 

The  course  of  cerebral  hemorrhage  of  the  .common  type  may 
present  many  variations.  Death  may  occur  almost  instantly,  but  this 
is  exceptional,  and  usually  the  result  of  inundation  of  the  ventricles. 
Death  may  occur  during  the  coma  from  the  great  size  of  the  clot 
and  the  exhaustion  of  the  patient.  After  coma  has  disappeared  and 
before  contracture  has  developed,  death  may  result  from  cerebritis 
arising  from  infection  of  the  clot.  During  this  early  period  pneumonia^ 
often  caused  by  the  aspiration  of  food  or  drink,  sometimes  carries  off 
the  patient.  A  succession  of  hemorrhages  taking  place  at  short  inter- 
vals, one  apoplectic  phase  succeeding  another,  are  nearly  always  fatal. 
After  the  initial  stroke,  and  usually  before  the  termination  of  the  coma, 
there  may  be  a  sudden  increase  in  all  the  symptoms.  The  breathing 
becomes  rapid,  irregular,  stertorous,  the  unconsciousness  more  profound. 
The  reflexes,  if  partly  present,  are  entirely  lost,  and  tetanic  spasms  or 
convulsions   appear  on   the  paralyzed   side.      The  temperature  bounda 


CEREBRAL   HEMORRHAGE  AND    THE  HEMIPLEGIC  STATE.       211 

upward  and  the  case  terminates  fatally  in  a  few  hours,  or  in  a  day  or  two. 
These  symptoms  are  due  to  the  hemorrhage  bursting  into  the  ventricles. 
If  the  fourth  ventricle  is  invaded,  nystagmus  appears  and  death  promptly 
follows.  In  the  so-called  ingravescent  apoplexy  the  hemorrhage  begins 
without  marked  stroke,  and,  steadily  continuing,  produces  the  apoplectic 
state  in  the  course  of  a  day  or  two,  finally  inundating  the  ventricles  and 
terminating  fatally. 

Recoveries  from  cerebral  hemorrhage  are  not  rare,  and  in  the 
majority  of  cases  the  hemiplegic  state  is  reached  and  the  stage  of  con- 
tractures is  developed.  Very  exceptionally  the  hemiplegia  practically 
disappears.  This  is  only  possible  when  the  hemorrhage  has  affected  the 
capsular  tracts  by  pressure  without  producing  rupture  of  their  fibers, 
and  then  the  clot  is  necessarily  small.  As  the  greatest  rarity  the  re- 
covery may  be  so  complete  that  no  trace  of  the  former  palsy  can  be 
discovered  by  clinical  examination. 

Clinical  Forms. — Cerebral  hemorrhage  presents  a  number  of  clini- 
cal forms,  the  most  usual  of  which  has  been  the  basis  of  the  preceding 
description.  Variations  in  localization  and  in  the  amount  of  ex- 
tra vasated  blood  endlessly  modify  the  type.  Within  the  field  of  the 
lenticulostriate  arteries  a  very  small  hemorrhage  may  produce  a  partial 
hemiplegia  or  a  monoplegia,  though  this  is  a  rare  form.  We  have  the 
occasional  form  of  hemiplegia  with  hemichorea,  or  hemiataxia,  or  hemi- 
athetosis.  There  is  the  form  of  hemiplegia  with  hemianesthesia  and 
another  in  which  hemichorea  and  hemianesthesia  are  combined.  A  rare 
form  consists  of  a  facial  monoplegia  with  hemianesthesia,  and  a  form 
presenting  hemianesthesia  and  motor  aphasia  has  been  noted.  Hemor- 
rhage into  the  posterior  lobes  of  the  brain  is  attended  by  the  apoplectic 
onset  or  insult  and  leaves  visual  or  aphasic  remnants  if  it  involves  the 
corresponding  radiations  and  pathways.  In  the  anterior  lobes  and  in  a 
large  portion  of  the  centrum  ovale  a  considerable  hemorrhage  may  take 
place  without  producing  lasting  symptoms.  In  these  hemorrhages  re- 
mote from  the  capsule  hemiplegic  symptoms  are  sometimes  present  at 
first  and  then  disappear  as  the  traumatic  effect  of  the  apoplexy  subsides. 
Primary  cortical  hemorrhage  is  exceptionally  encountered.  The  clot  is 
usually  small,  owing  to  the  small  caliber  of  the  cortical  arteries  ;  the 
stroke,  therefore,  is  slight  or  absent,  but  stupor  and  semicoma  may  be 
present.  The  symptoms  produced  are  those  of  an  irritant  lesion.  If  it 
occurs  in  the  motor  zone,  repeated  limited  convulsions  of  a  Jacksonian 
type  are  likely  to  occur  and  may  become  generalized.  Hemorrhages 
into  the  pons  and  medulla,  if  not  immediately  fatal,  give  rise  to  local- 
izing symptoms  and  cranial-nerve  disorders  that  have  already  been  dis- 
cussed, including  the  numerous  crossed  paralyses. 

Cerebellar  hemorrhage  usually  presents  a  very  sudden  onset,  but 
there  is  correspondingly  much  less  disturbance  of  the  mind  and  con- 
sciousness than  occurs  in  the  cerebral  variety.  The  patient  falls, 
vomits,  and  ex]5eriences  intense  vertigo.  Attempts  to  sit  or  stand 
greatly  increase  the  vertigo  and  vomiting  and  may  render  the  horizontal 
attitude  obligatory.  If  the  lesion  approaches  the  middle  peduncle,  forced 
movements  or  rigid  positions  may  be  induced.     These  may  impel  the 


212  DISEASES  OF   THE  BRAIN  PROPER. 

patient  strongly  to  the  right  or  left,  backward  or  forward,  and  in  the  recli- 
ning posture  cause  marked  curving  of  the  trunk  in  corresponding  direc- 
tions. Ataxia  and  asthenia  in  the  extremities  are  immediately  produced, 
and  tetanoid  spasms  may  appear.  Sensory  disturbances  are  fleeting  or 
absent.  Later  on  the  preponderance  of  symptoms  is  on  the  side  of  the 
lesion  if  it  is  unilateral,  but  if  pressure  occurs  on  the  pyramidal  tracts 
above  the  decussation,  crossed  symptoms  are  presented.  Cranial-nerve 
impairment  is  likely  to  be  present  from  irritation  of  the  nuclei  and 
pressure  on  the  floor  of  the  fourth  ventricle  may  induce  dangerous 
pneumogastric  complications.  Should  this  ventricle  be  flooded,  bulbar 
symptoms  are  induced  and  death  promptly  follows.  Much  similarity 
is  presented  by  attacks  of  labyrinthian  vertigo,  and  in  a  first  attack  the 
diagnosis  may  be  impossible.  A  history  of  preceding  attacks  and  of 
ear  disease  is  significant.  If  the  cerebellar  hemorrhage  involves  the 
auditory  nerve,  the  two  symptom  groups  coincide. 

The  diagnosis  of  cerebral  hemorrhage  is  often  difficult  and  some- 
times impossible.  Its  consideration  falls  into  two  parts  :  (1)  The  diagnosis 
during  the  apoplectic  state  and  (2)  the  diagnosis  after  the  apoplectic  state. 

Shortly  after  the  onset  of  the  stroke  we  have  to  ask  ourselves 
whether  the  case  is  one  of  syncope,  poisoning,  or  alcoholic  intoxi- 
cation. If  one-sided  symptoms  can  be  detected,  all  of  these  conditions 
may  be  excluded,  and  each  has  some  distinctive  symptom  that  one  on 
his  guard  may  detect.  The  pale  face,  fluttering  pulse,  and  sighing 
respiration  of  syncope,  the  contracted  pupil  of  opium,  the  smell  of 
alcohol  on  the  breath,  etc.,  are  suggestive,  and  taken  with  the  history 
of  the  onset,  when  obtainable,  are  nearly  sufficient.  But  cerebral  hemor- 
rhage may  come  on  during  drunkenness,  or  a  hemiplegic  case  may  be  given 
stimulants.  Uremia  is  more  difficult  to  difi'erentiate,  and  may  occasionally 
counterfeit  all  the  indications  of  cerebral  apoplexy.  Examination  of 
the  urine  may  throw  light  on  the  situation,  but  it  is  to  be  remembered 
that  the  conditions  giving  rise  to  uremia  are  those  usually  associated 
with  arterial  disease  in  the  brain.  Most  uremic  comatose  cases,  at  some 
period,  present  vomiting,  headache,  motor  excitement  and  spasmodic 
restlessness,  in  which  paralytic  features  are  lacking.  The  coma  is  rarely 
profound  at  first.  Meningeal  hemorrhage  may  be  easily  mistaken  for 
cerebral  hemorrhage,  as  stupor,  coma,  convulsions,  and  paralysis  are 
produced  by  both.  The  meningeal  form,  however,  usually  follows 
injury,  and  comes  on  slowly  or  after  a  distinct  interval.  It  is  often 
marked  by  irritation  of  cranial  nerves  and  early  bilateral  convulsions. 
The  epileptic  attack  usually  has  a  history  of  anterior  convulsions, 
presents  clonic,  tonic,  and  stuporous  stages,  and  is  quickly  and  com- 
pletely recovered  from.  Attacks  o^ focal  epilepsy  may  indicate  a  cortical 
hemorrhage,  but  are  common  to  all  diseased  conditions  of  the  cerebral 
jnotor  surface.  Every  case  must  be  carefully  analyzed,  and  often,  even 
Ihen,  only  a  presumptive  diagnosis  can  be  finally  reached.  Hysteria  in 
rare  cases  produces  an  imitation  of  cerebral  hemorrhage  that  is  ex- 
tremely faithful  to  the  type.  The  attack,  hovfever,  usually  occurs  under 
circumstances  of  emotional  and  psychical  disturbances  indicative  of 
hysteria.      The  face  is  rarely  involved,   Babinski's   toe-sign  is  absent. 


CEREBRAL   HEMORRHAGE  AND    THE  HEMIPLEGIC  STATE.       213 

and  sensory  stigmata  are  commonly  present.  The  age  and  clinical 
history  are  also  significant.  In  general  paresis  apoplectiform  seizures 
are  common,  and  the  differential  diagnosis  during  the  attack  may  be 
very  difficult.  A  history  of  mental  confusion,  childishness  of  conduct, 
forgetful ness,  unsteadiness  upon  the  feet,  and  syphilitic  iiifection  would 
favor  the  paretic  side  of  the  question.  Almost  complete  recovery  from 
the  stroke  may  then  be  expected  in  a  majority  of  cases. 

After  the  early  apoplectic  symptoms  have  persisted  many  hours  or 
have  subsided,  an  organic  lesion  can  usually  be  determined  from  the 
hemiparalytic  features.  The  important  question  regards  the  nature  of 
the  vascular  accident.  Is  it  rupture  or  occlusion  that  has  taken  place  ? 
Have  we  to  do  with  hemorrhage  or  with  infarction  ?  Are  we  in  the 
presence  of  extra vasated  blood  with  a  tendency  to  encapsulation,  or  con- 
fronted by  thrombosis,  the  precursor  of  softening?  It  is  a  question 
of  importance,  both  as  to  treatment  and  prognosis.  It  is  sometimes  an 
unsolvnble  problem,  but  should  never  be  neglected.  At  the  end  of  the 
next  chapter  a  differential  table  is  given,  to  which  attention  is  now 
directed.  In  a  general  way  we  may  say  that  the  following  points  favor 
a  diagnosis  of  cerebral  hemorrhage  :  Sudden  onset,  absence  of  syphilis, 
and  endocarditis,  the  presence  of  strong  cardiac  action  comparatively 
early,  high  arterial  tension,  marked  coma  and  cyanosis,  lowered  rectal 
temperature  and  raised  unilateral  temperature,  convulsions  involving 
the  whole  of  one  side,  paralysis  involving  the  whole  of  one  side,  early 
improvement  in  the  paralysis  most  marked  in  the  leg,  lack  of  perma- 
nent sensory  disturbances,  the  presence  of  complete  hemianesthesia  in 
the  absence  of  hysteria,  the  development  of  postapoplectic  tremor,  and 
athetosis. 

The  topical  diagnosis  must  follow  the  general  considerations  laid 
down  in  the  discussion  of  the  subject  of  cerebral  localization.  Atten- 
tion is  again  called  to  the  fact  that  the  above  description  is  dominated 
by  the  clinical  aspects  of  the  usual  capsular  variety  of  cerebral 
hemorrhage. 

Prognosis. — A  cerebral  hemorrhage  is  always  of  serious  import,  as 
it  is  a  conclusive  demonstration  of  wide-spread  and  threatening  arterial 
disease  in  the  encephalon.  However  slight,  it  implies  the  probability 
of  a  recurrence.  About  two-thirds  of  all  the  cases  survive  the  first 
attack,  one-third  the  second,  and  very  few  the  third.  The  size  and 
location  of  the  clot  are  important  considerations.  The  prognosis  is 
grave  in  proportion  to  the  violence  of  the  attack  and  the  depth  and 
duration  of  the  coma.  Coma  lasting  three  days  seldom  ends  in  recov- 
ery. The  appearance  of  Cheyne-Stokes  respiration  or  indications  of 
ventricular  flooding  practically  mean  death.  The  occurrence  of  con- 
vulsions is  a  serious  feature.  Pneumonia  is  almost  invariably  fatal. 
Acute  bedsore  and  acute  joint  disease  are  usually  followed  by  death. 
A  recurrence  of  coma  or  a  sudden  elevation  of  temperature  or  repeated 
apoplectic  features  imply  a  fatality. 

Unless  there  is  some  improvement  in  the  paralysis  at  the  end  of  the 
first  week,  it  is  likely  to  be  permanent.  The  appearance  of  contractures 
implies  lasting  functional  loss  wherever  they  develop.      The  state  of 


214  DISEASES  OF  THE  BRAIN  PROPER. 

contracture  commences  from  twenty  days  to  three  or  four  months  after 
the  stroke.  The  shoulder  and  hip  movements  improve  more  than  the 
knee  and  elbow  ;  the  ankle  and  wrist,  toes  and  fingers,  progressively 
decline  in  recuperative  prospects.  The  lower  extremity  surpasses  the 
upper  both  in  point  of  time  and  extent  of  recovery.  Considerable 
improvement  may  be  anticipated  during  the  first  two  or  three  months, 
and  then  much  slighter  progress  to  the  end  of  the  first  year  or  eighteen 
months.  Thereafter  the  case  will  be  practically  stationary.  The  dura- 
tion of  life  among  apoplectics  is  about  five  years,  according  to  Dana,  and, 
as  he  points  out,  a  stroke  may  be  a  conservative  measure,  enforcing  an 
inactivity  that  prevents  arterial  strain  and  thereby  prolongs  life. 

Treatment. — If  a  positive  diagnosis  of  cerebral  hemorrhage  is 
made,  immediate  active  treatment  should  be  instituted,  but  in  doubtful 
cases  a  masterly  inactivity — an  armed  neutrality — is  the  proper  course  ; 
there  are  many  who  think  it  the  only  course.  The  important  indication 
is  to  reduce  arterial  tension,  to  discount  the  pressure  at  the  site  of  hem- 
orrhage. When  the  case  is  seen  immediately  after  the  stroke  the  head 
should  be  raised,  an  ice-cap  applied,  and  faithful  carotid  compression  on 
both  sides  of  the  neck  employed  for  forty  minutes.  Meanwhile  the 
blood  should  be  directed  to  the  lower  extremities  by  having  them  swathed 
in  hot  compresses  and  by  the  intelligent  application  of  mustard.  Three 
drops  of  emulsified  croton  oil  serve  to  practically  bleed  the  patient 
into  his  abdominal  vessels  and  at  the  same  time  unload  the  bowels. 
Regarding  venesection,  the  forces  are  still  divided.  In  plethoric,  con- 
gested, livid  cases  with  strong  cardiac  action  it  may  properly  be  used. 
Aconite  and  veratrum  are  by  some  accounted  equally  valuable  to 
bleeding,  but  they  must  be  given  in  frequently  repeated,  competent 
doses.  For  instance,  aconitia,  -^^-^  of  a  gr.,  or  fresh  Norwood's  tincture 
of  veratrum,  two  drops  every  twenty  minutes  until  effects  are  produced. 
Bromids  and  ergot  are  only  mentioned  to  be  condemned.  In  some 
cases  a  failing  heart  requires  active  stimulation,  and  alcohol  and  strych- 
nin best  serve  the  purpose. 

In  most  cases  the  hemorrhage  reaches  its  maximum  within  three 
or  four  hours  and  the  damage  is  done.  Thereafter  the  indication  for 
treatment  is  solely  to  jjrevent  a  recurrence,  and  that  means  to  keep  the 
arterial  tension  down.  Quiet,  warmth,  liquid  diet,  if  any,  free  bowels, 
cleanliness  to  prevent  bedsore,  the  administration  of  cardiac  sedatives  ; 
attention  to  the  bladder,  which  is  likely  to  distend  and  overflow ;  care 
to  prevent  aspiration  pneumonia,  from  food,  mucus,  or  a  septic  con- 
dition of  the  mouth,  and  readiness  to  meet  recurrent  hemorrhages  or 
ingravescent  apoplexy  by  carotid  pressure  will  answer  the  major  require- 
ment. Ligation  of  the  carotid  is  not  a  well-established  proceeding, 
and  carotid  compression  must  be  used  with  circumspection  and  intelli- 
gence. In  the  aged  and  atheromatous  it  may  produce  convulsions  or 
serve  to  increase  the  coma.  The  effect  in  controlling  the  circulation 
may  be  observed  in  the  usually  prominent  and  throbbing  temporals  and 
in  the  color  of  the  face.  Suggestions  of  early  trephining  and  evacu- 
ating the  clot  have  been  made.  If  rupture  of  the  motor  path  occurs 
directly  the  extravasation  of  blood  takes  place,  further  surgical  lacera- 


CEREBRAL   HEMOREHAGE  AND    THE  HEMIPLEGIC  STATE.       215 

tion  can  scarcely  improve  matters.  If  purulent  cerebritis  develop  in 
the  clot,  trephining  to  drain  such  a  focus  may  reasonably  be  attempted 
in  this  otherwise  fatal  complication. 

As  soon  as  the  apoplectic  coma  has  passed  away,  gentle  massage  of 
the  paralyzed  side  and  exercise  of  all  the  paralyzed  muscles  by  mild 
faradism  should  be  instituted.  The  purpose  should  be  clearly  in  mind 
to  secure  as  nuieh  improvement  during  the  first  month  as  possible  and 
to  postpone  to  the  utmost  the  appearance  of  contracture.  A  muscle  that 
may  feebly  respond  to  volitional  control,  perhaps  to  the  associated  action 
of  the  sound  hemisphere,  is  rendered  perfectly  useless  by  contracture. 
From  the  onset  extremely  gentle  passive  movements  of  all  the  joints  to 
their  full  range  should  be  employed  every  two  or  three  hours.  Every 
one  is  familiar  with  the  rapidity  with  which  muscular  and  joint  stiffness 
appears  in  splinted  extremities.  In  these  hemiplegic  cases  the  limbs  are 
splinted  by  paralysis.  As  soon  as  there  is  any  reappearance  of  volun- 
tary motion  the  patient  should  be  encouraged  to  exercise  it.  These 
measures  are  usually  postponed  to  the  end  of  ten  days  or  a  fortnight  in 
fear  that,  by  instituting  them  early,  the  brain-lesion  may  in  some  way 
be  increased.  Certainly  any  violent  or  severe  measure  is  most  strongly 
to  be  deprecated,  but  a  common-sense  application  of  the  foregoing  direc- 
tions will  be  found  to  yield  encouraging  results. 

When  contractures  appear,  every  effort  should  still  be  persistently 
made  to  counteract  their  deforming  effect.  We  are  familiar  with  the 
vicious  attitudes  they  produce.  In  the  upper  extremity  the  extensors 
should  be  encouraged  by  massage,  electricity,  and  forced  passive  move- 
ments to  overcome  the  usual  flexor  supremacy.  Similarly,  in  the  lower 
extremity  the  equinovarus  should  be  overcome,  if  possible,  by  stimu- 
lating the  antero-external  muscles  of  the  leg.  Rigidity  at  the  knee  is 
less  objectionable.  Every  additional  week  of  suppleness  may  mean 
increased  voluntary  control.  Now,  also,  the  patient  should  be  constantly 
encouraged  to  concentrate  his  attention  upon  the  paralyzed  side  and 
repeatedly  attempt  to  move  the  paralyzed  muscles,  aiding  the  effort  by 
the  simultaneous  use  of  the  sound  side  in  executing  the  wished-for 
movements.  Weakness  of  the  sound  side  may  defeat  efforts  at  walkings 
unless  the  patient  is  greatly  encouraged  and  strongly  supported.  The 
distrust  of  their  strength  and  preference  for  inactivity  must  sometimes 
be  actively  met  by  the  encouragement  and  authority  of  the  physician. 
After  two  years  no  further  gain  is  to  be  expected,  but  even  then  loco- 
motion may  be  facilitated  by  orthopedic  apparatus  or  by  a  tenotomy  of  the 
heel-tendon.  There  are  very  few  hemiplegics  who  escape  more  or  less 
persistent  medication  with  iodid.  Aside  from  syphilitic  eases  it  can 
not  be  strongly  urged.  As  a  treatment  of  the  basic  arterial  state, 
however,  it  often  has  a  legitimate  place,  and  therein  may  be  prophy- 
lactic of  a  second  attack  of  hemorrhage.  Too  often  it  seems  to  degrade 
the  patient's  general  health  without  corresponding  benefit.  It  should 
go  without  saying  that  general  hygienic  and  tonic  measures  are  always 
indicated.  The  enforced  inactivity  of  the  hemiplegic  favors  intestinal 
atony  and  cutaneous  sluggishness,  which  require  watchful  and  intelligent 
management. 


216  DISEASES  OF   THE  BRAIN  PROPER. 


CHAPTER  VII. 
CEREBRAL  SOFTENING. 

The  term  "  cerebral  softening  "  is  open  to  objection  for  several  rea- 
sons, but  usage  has  confirmed  its  rank,  "  Softening  of  the  bram  "  is  g 
lay  expression  usually  applied  to  dementia,  and  based  upon  somewhat 
erroneous  notions  of  the  condition  of  the  brain  in  such  cases.  By 
cerebral  softening  is  here  meant  the  retrograde  process  in  vascular  terri- 
tories of  the  brain,  occasioned  by  arterial  obliteration  and  local  depriva- 
tion of  blood-supply.  It  is  an  infardion  process  exactly  similar  to  that 
which  is  common  in  the  spleen  and  kidney.  The  brain-structure,  how- 
ever is  not  of  a  uniform  functional  value,  and  a  cerebral  infarct  in  the 
majority  of  instances  destroys  specific  brain-powers  instead  of  simply 
reducing  the  capacity  of  the  whole,  as  in  the  abdominal  organs  men- 
tioned. In  addition  it  gives  rise  to  secondary  conditions  similar  to 
those  following  cerebral  hemorrhage.  It  is  to  Virchow  that  we  owe 
our  first  exact  knowledge  of  the  genesis  of  cerebral  softening.  Pre- 
viously the  softened  atrophic  area  was  attributed  to  inflammation  or  some 
vague  morbid  process.  We  know  now  that  the  immediate  cause  of  the 
encephalomalaeia  is  the  occlusion  of  the  cerebral  vessel  that  supplied 
the  diseased  portion.  This  obliteration  of  the  lumen  of  the  artery 
arises  (1)  from  thrombotic  obstruction  developing  on  the  site,  or  (2) 
from  plugging  by  an  embolus  starting  at  a  distance,  or  (.3)  from  local 
thrombosis  following  the  lodgment  of  irritant  emboli. 

When  a  cerebral  artery  is  occluded,  the  blood-supply  of  a  tolerably 
definite  territory  is  cut  oif  because  of  the  anastomotic  defects  of  the 
cerebral  circulation.  In  the  case  of  a  sizable  vessel  the  center  of  its 
arterial  field  is  wholly  deprived  of  blood,  but  the  margin  is  only  rela- 
tively impoverished,  as  there  is  some  overlapping  of  these  vascular 
territories,  by  slight  anastomoses  and  in  some  cases  by  direct  anastomotic 
relations  with  the  veins.  The  moment  an  artery  is  closed  its  distal 
portion  is  deprived  not  only  of  blood,  but  of  blood-pressure,  and,  aided 
by  its  own  resiliency,  it  tends  to  collapse.  This  gives  opjjortunity  for 
back  pressure  from  the  return  or  venous  circulation,  and  the  territory 
deprived  of  arterial  inflow  may  become  the  seat  of  venous  congestion. 
Moreover,  the  arterioles  deprived  of  their  nutrient  contents  are  disposed 
to  promptly  degenerate,  and  thus  arise  the  punctate  hemorrhages  so 
commonly  found  in  comparatively  recent  cases  of  cerebral  thrombosis. 
Subsequently,  retrogressive  changes  take  place  looking  to  the  removal  of 
the  mortifying  focus.  Fatty  degeneration  and  phagocytosis  go  on  rapidly. 
The  coloring-matter  of  the  extravasated  blood  finally  alone  remains. 
Repair  takes  place  about  the  focus  of  disease,  and  it  becomes  encapsulated. 
In  some  infarcts  of  minor  size  cicatrization  ensues,  and  a  scar  is  left  to 
mark  the  location  of  the  vascular  lesion. 

Pathological  Anatomy. — The  first  eflect  of  arterial  occlusion  is 


CEREBRAL  SOFTENING.  217 

to  cause  anemia  in  the  distal  portion,  and  the  territory  of  distribution 
becomes  blanched.  The  tissues  degenerate,  necrosis  follows,  and  lohite 
softening  is  produced.  If,  from  the  return  circulation  and  local  punctate 
hemorrhages  the  strangled  area  becomes  suffused  and  infiltrated  with 
blood,  color  is  added  and  red  softening  is  presented.  Finally,  as  resorp- 
tion takes  place  and  degeneration  becomes  complete  a  yellow  color  from 
the  remnants  of  the  hemic  pigment  marks  the  softened  and  perhaps 
encapsulated  tissue,  giving  rise  to  the  name  yelloiD  softening.  The  three 
appearances  are  but  stages  of  the  same  process,  but  white  softening  is  not 
necessarily  followed  by  the  red  and  yellow  changes.  The  red  appear- 
ance, due  solely  to  the  hemorrhagic  element,  appears,  if  it  appears  at 
all,  after  a  few  hours  or  a  few  days,  depending  upon  the  activity  of  the 
venous  back  pressure  and  the  degeneration  of  the  arterioles. 

In  a  very  few  days  after  arterial  obstruction  has  occurred  the  corre- 
sponding cerebral  tissue  presents  a  marked  appearance  of  degeneration. 
It  is  a  fact  of  practical  bearing  that  nerve-cells,  deprived  of  their 
nutritive  supply  for  about  forty-eight  hours,  are  permanently  ruined. 
The  softening  focus  is  infiltrated  with  serosity  and  the  cellular  and  neu- 
roglial elements  are  already  breaking  up.  The  myelin  separates  into 
droplets  and  is  rapidly  taken  up  by  migratory  leukocytes,  which  attain 
large  proportions  and  have  by  some  been  described  as  granular  bodies. 
The  degenerating  foci.is  shrinks  and  softens.  If  situated  beneath  the 
pia,  the  resulting  depression  is  filled  with  a  turbid,  milky  fluid,  and  the 
soft  meninges  are  thickened  and  highly  vascular.  It  becomes  impos- 
sible to  strip  the  pia  from  the  gyri  of  the  softened  area  without 
decorticating  them.  The  cortex  is  pale  and  friable,  the  white  substance 
softened  often  to  difiluence.  In  old  foci  of  softening  the  surrounding 
tissue  is  thickened,  especially  in  its  neuroglial  makeup,  and  presents  an 
indurated  wall  within  which  a  yellowish  fluid  substance  containing  fat- 
crystals  and  amorphous  matter  represents  the  former  cerebral  structure. 
Yellow  softening  may  be  found  at  the  end  of  six  weeks,  but  is  a  feature 
of  old  lesions.  These  may  even  become  calcareous.  Cicatrization — the 
fibrous  obliteration  of  small  softenings — has  been  already  mentioned. 
In  some  cases  the  softened  focus  becomes  infected,  as  by  an  embolus 
from  infectious  endocarditis,  or  from  pneumonia,  or  from  any  infection 
atrium,  and  a  secondary  true  encephalitis  is  developed.  This  rapidly 
goes  on  to  abscess  formation,  frequently  with  putrid,  offensive,  gangren- 
ous contents.  Thrombosis  occurring  in  the  perforating  arteries  of  the 
base,  which  are  entirely  without  anastomoses,  or  in  the  deep  cortical 
branches  which  penetrate  the  centrum  ovale,  produces  rounded  islets  of 
necrosis,  which  in  time  may  become  encapsulated  and  contain  only 
serous  fluid. 

At  the  seat  of  arterial  obliteration  arising  from  local  thrombosis  we 
find,  in  recent  cases,  a  partially  or  completely  organized  clot  adherent  to 
a  spot  or  ring  of  endarteritis  or  atheromatous  thickening.  An  embolus 
does  not  at  first  present  adhesions  to  the  intima.  It  may  be  made  up  of 
pure  fibrin  from  the  endocardium,  or  calcareous  particles  originating 
in  cardiac  or  arterial  atheroma.  Hydatids,  filaria,  and  any  minute 
substance  finding  access  to  the   blood-stream   may   furnish  a  cerebral 


218  DISEASES   OF  THE  BRAIN  PROPER. 

embolus.  In  about  nine  cases  out  of  ten  it  originates  in  or  near  the 
heart,  and  in  fortunate  cases  the  exact  location  of  its  origin  has  been 
detected.  Ordinarily  an  embolus  lodges  at  the  branching  of  an  artery, 
from  which  point  the  thrombotic  fibrin  deposit  extends.  If  the  em- 
bolic mass  be  calcareous,  it  may  abrade  the  intima  and  give  rise  to  a 
dissecting  aneurysm,  which  in  turn  leads  to  occlusion  and  thrombosis. 
The  size  of  the  softening  depends  entirely  upon  the  size  and  relations  of 
the  occluded  vessel. 

The  location  of  cerebral  softening  is  more  frequent  on  the  left  than 
on  the  right  side  of  the  brain.  The  left  middle  cerebral  is  especially 
selected,  and  its  perforating  or  basilar  are  more  frequently  involved  than 
its  cortical  branches.  This  is  due  perhaps  to  the  fact  that  cardiac 
emboli  following  the  direct  route  tend  to  enter  the  vessels  that  most  con- 
form to  the  straight  line  of  their  momentum.  These  are  also  the 
favorite  seats  of  atheroma.  The  anterior  capsulogangliar  region  is  the 
most  common  site  of  cerebral  softening,  followed  in  decreasing  frequency 
by  the  posterior  capsulogangliar  region,  the  cortical  territory  of  the 
middle  cerebral,  that  of  the  posterior  cerebral,  then  that  of  the  anterior 
cerebral.  Softening  is  rare  in  the  cerebellum  and  in  the  bulb,  except 
in  syphilitic  endarteritis,  which  frequently  implicates  the  brain-stem. 
In  rare  cases  we  encounter  a  bilateral  and  symmetrical  softening.  In 
some  instances  this  may  be  explained  by  thrombosis  or  embolism  start- 
ing in  the  circle  of  Willis.  For  instance,  an  atheromatous  patch  at  the 
bifurcation  of  the  basilar  may  furnish  a  plug  to  the  left  side,  and  circu- 
lation on  that  side  being  proportionately  reduced,  the  next  embolus  goes 
to  the  right  side.  In  some  cases  there  are  numerous  foci  of  softening. 
Softening  may  affect  only  the  gray  cortex,  or  the  wdiite  subcortical 
substance,  or  both.  The  extent  of  necrosis  depends  always  on  the 
damaged  arterial  supply.  If  the  Sylvian  trunk  be  occluded,  the  entire 
sensorimotor  zone  is  softened  as  well  as  the  subcortical  white  substance 
as  deep  down  as  the  basal  ganglia.  If  the  thrombosis  or  arterial  stagna- 
tion implicates  only  the  short  cortical  branches,  local  death  of  the  brain- 
mantle  alone  may  follow.  Again,  if  the  arterial  disturbance  affects  the 
long  penetrating  arteries  that  traverse  the  cortex  to  supply  the  centrum 
ovale,  the  cortex  may  be  spared. 

Etiology. — The  ultimate  causes  of  cerebral  softening  are  those  of 
the  arterial  diseases,  already  considered,  that  underlie  thrombosis  and 
embolism.  In  a  rough  way  we  may  say  that  thrombosis,  usually  a 
sequence  of  atheroma  and  arteriosclerosis,  pertains  to  advanced  age, 
alcohol,  lead,  gout,  and  syphilis,  and  that  embolism  is  an  accident  of 
left  endocarditis  due  to  acute  rheumatism  and  the  infectious  of  pneu- 
monia, typhoid,  diphtheria,  the  puerperium,  etc.  As  a  presumptive 
rule,  we  may  also  say  that  cortical  softenings  are  commonly  due  to  em- 
bolism and  occur  most  frequently  in  youth  ;  that  those  of  the  central 
area  are  due  to  thrombosis  and  take  place  in  advanced  years.  Throm- 
bosis is  favored  by  a  weak  heart  and  sluggish  arterial  current  of  low 
tension,  conditions  ordinarily  found  in  cachectic  and  marantic  patients 
and  favored  by  sleep.  Embolism  is  favored  by  any  act  that  throws 
a  load    upon  the  heart  and  produces  cardiac   stimulation.     Vigorous 


CEREBRAL   SOFTENING.  219 

muscular  efforts,  sudden  emotion,  or  merely  rising  to  the  feet  from  a 
reclining-  position  may  start  an  embolus  when  friable  arterial  or  cardiac 
vegetations  exist.  Very  exceptionally  a  cerebral  artery  is  obliterated 
by  conditions  arising  outside  its  lumen,  as  by  a  rapidly  growing  tumor 
or  other  compression  factor  acting  with  some  degree  of  ]>romptness. 
Unless  the  compression  is  brought  rapidly  to  bear,  the  circulation  is 
able  to  adjust  itself.  Heredity,  sex,  age,  temperature,  barometric 
pressure,  and  the  seasons  are  of  much  less  significance  than  in  cerebral 
hemorrhage. 

Symptoms. — The  early  symptoms  of  cerebral  softening  are  domi- 
nated by  the  rapidity  with  which  the  arterial  current  is  blocked 
and  by  the  importance  and  size  of  the  vessel  involved.  As  a  matter  of 
fact,  embolism  is  capable  of  producing  instantaneous  blocking  of  the 
arterial  lumen,  and  symptoms  of  great  violence  at  the  onset  to  some 
degree  indicate  embolism  if  hemorrhage  is  excluded.  On  the  other 
hand,  while  thrombosis  usually  produces  progressive  symptoms,  a  slowly 
growing  thrombic  arterial  lining  may  cause  a  sudden  deposit  of  fibrin 
from  the  blood,  and  intense  symptoms  are  thereby  precipitated.  Again, 
a  small  embolus  may  only  partially  choke  the  blood-current,  and  the 
slowly  developing  occlusion  is  marked  by  the  deliberately  advancing 
symptoms  and  prodromata  of  the  stroke.  Cerebral  thrombosis,  therefore, 
presents  both  (1)  an  abrupt  and  (2)  a  progressive  onset,  with  different 
cerebral  symptoms  immediately  resulting,  but  with  the  same  terminal 
conditions. 

The  Abrupt  Onset. — With  none  or  only  momentary  confusion  the 
patient  has  a  stroke  or  cerebral  attack,  followed  by  loss  of  conscious- 
ness, perhaps  even  by  the  development  of  coma.  Hemiplegia  develops, 
consciousness  returns,  and  more  or  less  paralysis  persists.  In  about  an 
equal  number  of  cases  consciousness  is  not  lost,  though  the  paralysis  is 
as  quickly  developed,  and,  as  a  rule,  the  mental  subjugation,  the  cerebral 
insult,  is  less  than  in  hemorrhage.  Many  cases  are  attacked  during 
sleep,  and  awake  at  their  usual  hour  with  no  appearance  of  stupor  and 
with  their  ordinary  mental  brightness.  A  very  significant  feature  of 
thrombosis  affecting  the  cortical  circulation  is  the  Jacksonian  or  limited 
convulsions  which  are  commonly  presented,  and  which  tend  to  repetition 
during  the  early  hours  and  days  of  the  illness  without  great,  often  with- 
out any,  disturbance  of  consciousness.  Distinguishing  softening  from 
hemorrhage,  we  seldom  encounter  the  retarded  strong  pulse,  the  subnormal 
temperature,  the  unilateral  heat,  the  congested  face,  the  respiratory  diffi- 
culty, and  the  prolonged  coma  so  characteristic  of  a  ruptured  cerebral 
vessel.  In  a  fair  proportion  of  all  cases  of  thrombosis  the  early  symp- 
toms are  progressive.  A  monoplegia  becomes  a  hemiplegia.  Paralysis 
beginning  in  the  leg  invades  the  entire  extremity,  reaches  the  upper 
limb,  implicates  the  face,  disturbs  speech  if  on  the  left  side  of  the 
brain,  and  finally  the  hemiplegia  is  complete.  This  is  due  to  the 
thrombus,  by  gradual  increase,  backing  down  the  artery  from  its  orig- 
inal place  of  development,  and  if  it  extend  into  the  circle  of  Willis 
the  opposite  Sylvian  artery  may  also  be  blocked.  When  the  basilar 
is  invaded  bulbar  symptoms  usher  in  a  fatal  termination.     Thrombosis 


220  DISEASES  OF  THE  BRAIN  PROPER. 

beginning  in  the  branches  of  the  middle  cerebral  may  first  produce  an 
aphasia;  lower  facial  paralysis  and  loss  of  power  in  the  limbs  of  the 
same  side  may  then  be  gradually  added.  The  distribution  of  the 
arteries  to  the  motor  region  makes  clear  the  sequence  of  events.  (See 
page  192.) 

The  Progressive  Onset. — When  the  arterial  obliteration  is  a  slow 
process  and  the  caliber  of  the  vessel  is  gradually  reduced,  disturbances  in 
the  poorly  irrigated  cerebral  district  are  likely  to  be  manifested.  In 
the  case  of  a  Sylvian  vessel  this  is  the  rule.  The  patient  complains 
of  more  or  less  transient  or  persistent  sensations  of  fullness,  heaviness, 
formication,  weakness,  pain,  or  other  vague  discomfort  in  the  face  or  in 
one  extremity,  or  merely  in  the  distal  part  of  an  extremity.  The  face 
at  the  same  time  may  show  transient  weakness,  the  leg  may  be  dragged 
a  trifle,  and  a  little  clumsiness  may  be  noticed  in  the  finer  finger-move- 
ments. Speech  very  often  is  disturbed,  presenting  various  slight  aphasic 
indications.  Any  or  all  of  these  symptoms  are  likely  to  be  most  marked 
toward  night  or  after  fatigue.  They  indicate  a  local  anemia  of  their 
respective  cerebral  mechanisms  and  a  lowered  nutrition  that  translates 
itself  in  paresthesias  and  paresis  and  foreshadows  paralysis.  In  many 
cases  the  cortical  irritation  shows  itself  in  twitchings  in  the  face  or  in 
the  extremities,  or  in  a  sudden  thickness  of  speech. 

Groups  of  such  symptoms  may  appear  several  times,  lasting  at 
intervals  for  a  day  or  two  and  then  recede  for  weeks  or  months. 
Finally  they  return  with  more  bruskness  and  severity,  convulsions 
may  ensue,  the  thrombosis  is  complete,  and  paralysis  is  permanently 
established. 

This  progressive  loss  of  cortical  circulation  is  to  some  extent  a 
part  of  the  physiology  of  senile  involution.  The  blood-current 
becomes  gradually  weaker  and  the  arterial  channels  progressively 
diminish  in  capacity.  The  heart  loses  its  force ;  the  fine,  delicate, 
cortical  vessels  are  most  affected ;  circulatory  stagnation  in  the  brain- 
mantle  is  favored,  nutrition  fails,  psychical  and  motor  and  sensory 
functions  are  reduced  in  activity,  and  dementia  is  inevitable.  In 
the  brains  of  the  aged,  multiple  foci  of  softening  are  commonly 
encountered. 

The  paralytic  state  may  thus  be  established  suddenly  with  or 
without  an  apoplectic  state,  or  may  advance  by  steps  and  be  pre- 
ceded by  numerous  warnings  and  significant  symptoms.  Softening 
once  established  has  the  tendency,  as  has  already  been  indicated,  to 
invade  adjoining  cerebral  areas,  related  through  the  arterial  supply. 
Hemiplegia  and  the  hemiplegic  state  are  common  results.  In  cases  of 
sudden  onset,  especially  if  marked  by  an  apoplectic  seizure,  the  hemi- 
plegia is  usually  complete  and  severe.  In  cases  of  less  active  onset, 
and  especially  in  those  of  gradual  development,  the  functional  loss  is 
less  profound  and  there  is  a  greater  tendency  to  subsequent  recession, 
leaving  only  a  monoplegia  or  a  monoparesis.  The  paralysis  may  be 
monoplegic  from  the  first,  and  softening  is  the  most  common  source  of 
the  cerebral  monoplegias.     In  the  same  way  aphasia  alone  may  indicate 


CEREBRAL   SOFTENING.  221 

the  cortical  disease.  Persistent  aphasia  in  all  its  varieties,  nine  times 
ont  of  ten,  is  dne  to  cerebral  softening.  In  the  same  way  the  cortical 
areas  of  half-vision  may  be  destroyed,  or  any  given  cortical  function 
mav  be  singly  selected  for  abolition. 

The  paralytic  state  due  to  softening  presents  practically  the  same 
course  and  tinal  deformities  that  mark  it  Avhen  resulting  from  cerebral 
hemorrhage  (see  p.  207).  At  first  flaccid,  the  permanently  para- 
lyzed limbs  show  increased  reflexes  after  about  three  weeks,  and  the 
usual  contractures  are  developed.  If  the  paralysis  in  a  given  member 
remain  unimproved  at  the  end  of  the  first  week,  it  is  likely  to  be 
permanent.  The  tendency  to  recession,  to  progressive  improvement,  is 
by  no  means  so  marked  as  in  hemorrhage.  While  the  traumatic  shock 
to  the  brain  is  less,  the  destruction  is  relatively  greater. 

Sensory  disturbances,  which  in  hemorrhage  ordinarily  disappear 
promptly,  are  commonly  persistent  in  the  paralytic  state  after  softening. 
Their  persistence  indicates  a  cortical  lesion  unless  hemiplegia  and  hemi- 
anesthesia coincide,  when  the  sensory  crossway  is  involved,  whatever  be 
the  lesion,  hysteria  being  excluded.  The  sensory  disturbances,  after 
cortical  softening,  are  paresthetic,  not  anesthetic.  This  is  due  to  the 
stratification  of  cortical  function,  sensation,  muscular  sense,  and  motion 
being  represented  at  increasing  depths  in  the  sensorimotor  zone,  as 
described  on  page  160.  That  sensation  is  not  abolished,  but  is  only 
disturbed,  is  due  to  its  probably  complete  bilateral  representation  in  the 
hemispheres. 

Course. — As  cerebral  softening  is  a  brain  accident,  the  result  of 
arterial  disease,  like  hemorrhage,  it  may  present  all  gradations  of  severity 
and  extent  and  numerous  clinical  forms.  Cases  marked  by  abrupt  onset 
with  a  well-marked  apoplectic  phase  may  sink  into  coma  and  die.  In 
proportion  as  the  onset  is  gradual  the  tendency  to  immediate  death  is 
lessened,  excepting  in  those  instances  where  progressive  invasion  of 
vascular  territories  shows  that  the  thrombotic  process  is  advancing 
toward  the  circle  of  Willis.  The  paralysis  or  aphasia  once  definitely 
developed,  there  is  still  a  tendency  to  improvement,  which  is  less 
marked  than  in  corresponding  cases  of  cerebral  hemorrhage.  Should 
the  softened  focus  become  infected,  an  acute  purulent  encephalitis  is 
likely  to  carry  off  the  patient.  This  complication  is  marked  by  ele- 
vation of  temperature,  sometimes  by  somnolence,  usually  by  convul- 
sions referable  to  irritation  in  or  about  the  diseased  area,  and  .is  fre- 
quently associated  with  a  pneumonia  or  an  acute  bedsore.  Months  and 
years  after  the  onset  of  the  disease  the  softened  focus  still  constitutes 
an  irritant  brain-lesion  which  may  cause  epileptoid  convnlsions.  It 
may  have  a  bad  influence  on  the  integrity  of  the  mind  and  be  followed 
by  insanity.  The  hemiplegic  state,  when  once  developed,  presents  the 
common  features  and  indications  described  in  the  preceding  chapter. 
When  multiple  softenings  occur,  the  clinical  picture  is  much  modified. 
A  right  facial  paresis,  with  aphasic  symptoms,  may  accompany  a  left 
brachial  monoplegia. 

Diagnosis. — The    diagnosis   of  cerebral    softening    often    presents 
man}  difficulties  and  sometimes  is  impossible.     In  the  great  majority  of 


222 


DISEASES   OF  THE  BRAIN  PROPER. 


cases,  however,  a  careful  scrutiny  of  all  the  data  enables  us  to  make  a 
positive  diagnosis,  and  in  a  fair  share  of  the  remaining  cases  a  strong 
presumption  can  be  established.  The  question  primarily  concerns  the 
arterial  occlusion.  After  the  age  often  and  up  to  forty  a  paralytic  attack 
suggests  embolism  or  syphilis.  Endocardial  disease,  a  recent  history 
of  acute  rheumatism  or  infectious  fever,  speaks  strongly  for  embolism. 
Practically  a  diagnosis  of  embolism  can  not  be  made  in  the  absence  of 
cardiac  symptoms.  After  the  age  of  seventy  years  the  presumption  is 
again  in  favor  of  softening,  but  from  forty  to  sixty-five  or  seventy 
hemorrhage  is  the  commoner  cause  of  paralysis.  A  history  of  syphilis, 
plumbism,  or  alcoholism  suggests  softening. 

The  mode  of  onset  may  clearly  indicate  softening.  Prodromata  and 
the  gradual  paralytic  invasion,  localized  spasms,  monoplegias,  aphasias, 
and  limited  paresthetic  areas  are  indicative  of  softening.  The  dispropor- 
tion between  the  paralysis  and  the  apoplectic  features  suggests  soften- 
ing. A  complete  hemiplegia  of  rapid  development  without  a  stroke  can 
hardly  be  due  to  hemorrhage.  A  pale  face,  weak  heart,  normal  temper- 
ature, and  practically  undisturbed  consciousness  all  favor  softening  as 
the  cause  of  a  paralytic  attack.  Multiple  palsies  and  bilateral  palsies, 
especially  if  symmetrical,  are  usually  due  to  softening.  Softening  occurs 
often  during  sleep  and  under  conditions  of  low  arterial  tension,  except 
in  embolism.  After  the  paralysis  has  been  established  it  is  likely  to 
persist,  though  in  children  and  young  adults  it  may  notably  improve. 

Many  of  the  clinical  features  of  softening  are  produced  by  tumors, 
but  ordinarily  new  growths  have  a  more  insidious  course  and  present 
the  cardinal  symptoms  of  headache,  vomiting,  optic  neuritis,  and 
vertigo.  Cerebral  abscesses  usually  furnish  a  history  or  evidence  of 
injury  or  otitis,  but  a  softened  area  may  be  infected  and  break  down 
into  an  abscess.  It  is  with  cerebral  hemorrhage  that  softening  is  most 
confused.  They  have  many  common  points.  For  instance,  syphilis 
and  alcoholism  may  cause  both,  and  both  have  apoplectic  onsets  and 
paralytic  sequels.  In  some  instances  the  differential  diagnosis  can  only 
be  made  out  in  the  light  of  the  subsequent  course  of  the  disease,  and 
in  a  small  number  of  cases  it  seems  quite  impossible  to  make  it.  The 
following  table  of  probabilities  will  serve  to  show  the  direction  a  pre- 
sumptive diagnosis  should  take  : 


Table  of  Differextial  Peobabilities  ix  Ceeebeal  Hemorrhage  axd 

Thrombosis. 


Peedisposixg 
coxditions. 


Hemorrhage. 


Frequent  before  three  years  of 
age,  and  between  forty  and 
sixty. 


Thrombosis. 


Common  in  old  age  and  in  young 
adults. 


Peri-arteritis  and  miliary  aneur-    Endarteritis,  atheroma,  endocar- 
y.sm  the  usual  antecedent.  ditis,  and  cachexiae. 


Heredity  often  marked. 


Heredity  rare. 


CEREBRAL  SOFTENING. 


223 


Table  of  Diffeeextial  Peobabilities  in  Ceeebeal  Hemoeehage  and 
Theombosis. — [Continued.) 


Hemorrhage. 

Thrombosis. 

Inciting 
Conditions. 

High  arterial  tension. 

Low  arterial  tension. 

Excitement,  efifort,  or  shock. 

Earely  excitement  or  effort,  ex- 
cept in  embolism.  Sleep  favors 
it. 

Onset 
Conditions. 

No  prodromata. 

Prodromata  common. 

Sudden  stroke  usual. 

Complete  stroke  rare. 

Coma  marked. 

Coma  slight  or  wanting. 

Eectal  temperature  reduced,  and 
surface  temperature   elevated 
on  the  paralyzed  side. 

Temperature  usually  unchanged. 

Congested  face  ;  respiratory  diffi- 
culties. 

Pale  face  :  no  respiratory  disturb- 
ance. 

Pulse  slow,  full,  bounding. 

Pulse  weak,  soft,  often  rapid. 

Motor  loss    usually   hemiplegic 
and  fullj'  developed  at  once. 

Motor  loss  often  monoplegic  and 
inclined  to  extend. 

General  convulsions  common. 

Limited  convulsions  common. 

COUESE. 

Eapid  improvement  in  motion. 

Slow  motor  improvement.  Ex- 
tension of  paralysis  often  ob- 
served. 

Foot  usually  gains  more  rapidly 
than  hand. 

Foot  often  gains  less  than  hand. 

Anesthesia  usually  fleeting. 

Paresthesia  persists. 

Persistent  aphasia  exceptional. 

Persistent  aphasia  and  other  cor- 
tical symptoms  common. 

Postplegic  athetosis,  trembling,  \  Postplegic    athetosis,  trembling, 
and  chorea  common.                          and  chorea  uncommon. 

Postplegic  convulsions  rare. 

Postplegic  convulsions  common. 

Spasmodic  weeping  and  laughter  ' 
common. 

Spasmodic  weeping  and  laughter 
exceptional. 

Prognosis. — Cerebral  softening  is  an  accident  following  such  a  wide 
variety  of  diseases  and  conditions  which  provoke  the  endarterial  process 
of  thrombosis  that  prognosis  can  not  be  generalized.  Every  case  has  its 
own  indications.  The  tendency  to  immediate  death  is  less  than  in  hem- 
orrhage, but  the  appearance  of  pneumonia,  or  an  acute  bedsore,  or  a 
sudden  elevation  of  temperature,  even  of  moderate  degree,  indicates  a 
grave  complication  and  a  probable  fatality.  In  embolic  cases,  if  it  is 
probable  that  the  embolus  is  infected,  as  in  infectious  endocarditis,  diph- 
theria, and  the  exanthemata,  the  outlook  is  much  darkened  by  the 
probability  of  acute  infectious  encephalitis  being  set  up  in  the  softened 
area,  to  be  followed    by  abscess  and  probably   by   death.     Advanced 


224  DISEASES  OF  THE  BRAIN  PROPER. 

years  are  against  the  patient.  In  every  case  the  prognosis  should  be 
held  in  reservation  for  a  week  until  it  is  evident  that  the  thrombosis  is 
not  spreading  and  that  local  infection  has  not  occurred.  The  tempera- 
ture is  here  a  vahiable  guide.  Persistent  severe  convulsions  commenc- 
ing early,  perhaps  present  at  the  onset,  are  of  grave  significance.  They 
point  to  involvement  of  the  cortex  and  meninges  on  the  one  hand,  or  of 
the  lateral  ventricles  on  the  other.  The  secondary  implication  of  the 
meninges  or  ependyma  over  the  softened  area  is  usually  limited,  but  in 
infected  cases  it  may  lead  to  a  generalized  inflammatory  process  of  the 
utmost  gravity.  When  the  first  fortnight  has  passed,  the  paralytic  state 
may  be  considered  established.  Contractures  and  deformities  are  there- 
after developed,  as  in  hemorrhage.  The  hemiplegic  state  presents  nothing 
dissimilar  to  that  following  arterial  rupture,  and  has  been  described  in 
a  previous  chapter.  The  condition  presented  by  a  given  case  of 
softening  at  the  end  of  the  first  month  is  likely  to  be  permanent.  This 
is  especially  true  after  middle  life.  There  is  also  the  possibility  of 
epileptoid  attacks  following  at  any  time,  and  the  persistence  of  the 
endarterial  disease  or  its  generalized  presence  constitutes  a  continual 
menace.  This  is  particularly  true  in  multiple  softenings  and  in  the 
bilateral  forms  such  as  that  which  furnishes  a  pseudobulbar  palsy. 

Treatment. — The  treatment  of  cerebral  softening  to  be  efficient 
must  antedate  the  occurrence  of  thrombosis.  In  a  word,  it  must  be 
prophylactic.  In  another  word,  it  must  be  the  treatment  of  the  arterial 
disease.  When  the  arterial  current  is  cut  off  we  yet  have  to  deal  with 
the  basic  disease  in  order  to  prevent  an  increase  of  the  thrombus  or  its 
repetition  and  to  cause,  if  possible,  its  diminution.  When  called  at  the 
onset  of  the  softening  in  the  early  hours  of  the  attack,  if  hemorrhage 
can  be  excluded,  the  treatment  consists  of  maintaining  a  masterly  inac- 
tivity. The  patient's  position  should  be  horizontal,  to  favor  the 
cerebral  circulation  ;  the  flagging  heart  may  be  encouraged  with  strych- 
nin ;  small  quantities  of  nourishment  should  be  administered  and  the 
functions  of  the  bowels  and  bladder  supervised.  If  hemorrhage  can 
not  be  excluded,  the  same  course  is  still  advisable,  but  if  hemorrhage  is 
diagnosed,  the  opposite  plan  of  treatment  for  that  condition,  already 
described,  should  be  instituted.  Purgation  and  venesection  can  not 
benefit  a  cerebral  territory  already  exsanguinated.  In  cases  of  embo- 
lism, cardiac  repose  is  to  be  encouraged  that  other  particles  may  not 
emigrate.  Bromid,  to  control  the  convulsions,  may  often  be  required. 
The  further  management  of  the  case  is  that  of  good  nursing.  The 
arterial  state  must  never  escape  attention.  Its  amenability  to  treatment 
governs  the  outlook  for  the  patient  and  the  probability  of  recurrence. 
When  the  paralytic  state  is  established,  its  management  is  the  same  as 
that  laid  down  in  the  previous  chapter,  and  for  the  terminal  monoplegia 
or  hemiplegia  the  indications  are  likewise  identical.  The  treatment  of 
aphasias  and  the  development  of  the  opposite-sided  speech-centers  have 
been  described  in  the  chapter  on  Aphasia. 


DISEASES   OF  THE   CEREBRAL    VEINS  AND  SINUSES. 


225 


CHAPTER  VIII. 
DISEASES  OF  THE  CEREBRAL  VEINS  AND  SINUSES. 

Anatomical  Considerations. — The  blood  entering  the  cranium  by 
the  internal  carotids  and  vertebrals  after  irrigating  the  encephalon  makes 
its  exit  mainly  by  the  internal  jugular  veins.  The  return  circulation 
from  the  ventricular  portion  of  the  cerebrum  and  the  callosal  portion 
of  the  hemispheres  is  by  the  Gallenic  veins  and  inferior  longitudinal 
sinus,  all  of  which  empty  into  the  straight  sinus.  From  the  convexity 
the  pial  veins  run  upward  and  open  into  the  superior  longitudinal  sinus 


Cmimunicafion.  through  parietal 

foramen  with  extei-nal  veins  of  skuU. 


Ext.  jugular  vein 


Int.  jugular 


Fig. 


-Diagram  showing  the  communicatious  existing  between  the  superior  longitudinal  and 
lateral  sinuses  and  the  external  veins,  indicated  in  the  figure  by  *  (Leube). 


in  a  forward  direction  against  the  slow  blood-current  of  this  dural 
channel.  Here  the  circulatory  conditions  are  rendered  still  more 
unfavorable  by  hydrostatic  pressure,  by  the  presence  of  trabecule  in  the 
sinuses  which  impede  the  flow  of  blood,  and  by  venous  retardation 
during  inspiration.  The  cerebellar  veins  empty  mainly  into  the  lateral 
sinuses.  Into  the  dural  sinuses  also  empty  many  veins  from  the  face 
and  scalp.  The  facial  vein  communicates  with  the  cavernous  sinus 
through  the  ophthalmic  vein.  The  veins  of  the  nasal  vault  open  into 
the  anterior  extremity  of  the  superior  longitudinal  sinus.  Numerous 
veins  of  the  scalp  along  the  median  line  have  a  similar  outlet.  Veins 
from  the  mastoid  process  and  its  cutaneous  surface  enter  the  lateral  and 
15 


226 


DISEASES  OF  THE  BBAIN  PROPER. 


petrosal  sinuses,  and  the  occipital  and  posterior  auricular  veins  are  con- 
nected with  the  lateral  sinus.  In  addition,  many  veins  of  the  cranial 
diploe  discharge  into  the  sinuses.  Finally,  the  sinuses  connect  with  the 
veins  of  the  spinal  canal. 


fExt,  Jugul.vein 


Communication  with  veins 
at  back  of  neck 


Fig.  89. — Diagram  showing  the  communications  existing  between  the  lateral  and  cavernous  sinuses 
and  the  external  veins,  indicated  in  the  figure  by*  (Leubej. 


The  cerebral  veins  are  subject  to  the  same  lesions  that  influence 
veins  elsewhere,  but  we  are  only  called  upon  to  consider  phlebitis  and 
venous  thrombosis.  They  are  usually  associated  and,  practically  speak- 
ing, severe  cerebral  symptoms  are  alone  produced  by  thrombi.  Throm- 
bosis may  occur  in  the  pial  vessels  of  the  convexity  and  extend  into 
the  longitudinal  sinus,  or,  beginning  in  the  sinus,  may  invade  the 
cortex  and  give  rise  to  localized  softening  and  focal  manifestations. 
The  entire  subject  may  be  conveniently  described  under  the  head  of 
Sinus  Thrombosis. 

SINUS  THROMBOSIS. 
Intracranial   sinus   thrombosis    occurs    more   frequently   even   than 
thrombosis  in  the  pelvic  veins,  or  in  those  of  the  lower  extremities.     It 


DISEASES   OF   THE   CEREBRAL    VEINS  AND  SINUSES.  ^'21 

is  favored  by  the  sluggishness  of  the  venous  current  and  the  other 
anatomical  peculiarities  above  indicated.  Septic  invasion  is  also  ex- 
tremely liable  from  the  relation  of  these  channels  to  the  cavities  of 
the  nose,  throat,  and  ear,  and  to  the  frequently  traumatized  surface  of 
the  face,  neck,  and  scalp.  It  occurs  in  two  forms, — the  marantic  and  the 
infective. 

Marantic  sinus  thrombosis,  or  primary  thrombosis,  is  a  local 
condition  occurring  usually  in  the  superior  longitudinal,  rarely  in  the 
lateral,  and  very  rarely  in  the  cavernous  sinus.  It  occurs  in  debilitated 
states,  and  is  most  common  at  the  two  extremes  of  life.  Exhausting 
diseases,  weakness  of  the  heart,  and  in  general  any  cachectic  state  pre- 
dispose to  it.  Prolonged  illness,  as  from  diarrhea,  typhoid  fever, 
pneumonia,  phthisis,  cancer,  malaria,  the  anemias,  etc.,  often  precede 
it.  Under  these  conditions  there  is  a  tendency  to  fibrin  deposit  and 
thrombus  formation  which,  once  started,  is  likely  to  extend.  Should  it 
commence  in  a  cortical  vein,  or  extend  from  a  sinus  to  the  brain-surface, 
Jacksonian  fits  may  be  produced. 

Usually  on  post-mortem  examination  the  thrombus  is  found  to 
involve  several  sinuses  and  their  tributary  veins.  When  the  entire 
lumen  of  a  cortical  vein  is  blocked,  the  drainage  of  its  territory  is  pre- 
vented and  localized  edema,  punctate  hemorrhage,  and  red  softening 
follow.  In  the  same  way  edema  occurs  in  the  superficial  parts  of  the 
face  and  head  which  drain  into  an  occluded  sinus.  Swelling  about  the 
eye  and  exophthalmos,  with  retinal  thrombosis  and  epistaxis  ;  swelling 
about  the  mastoid,  over  the  vertex  or  occiput,  is  produced  by  the  throm- 
botic closing  of  the  sinuses  respectively  related  to  these  regions.  When 
the  lateral  sinus  is  involved,  the  thrombus  may  extend  down  the  internal 
jugular  and  be  found  as  a  firm,  palpable  cord  in  the  neck.  In  marantic 
thrombosis  the  clots  are  firm  and  non-adherent  to  the  walls  of  the  vein 
or  sinus, — that  is,  they  are  not  inflammatory.  They  tend  to  organize 
or  resorb  and  do  not  disintegrate.  Reestablishment  of  the  circulation 
in  the  sinus  is  therefore  possible,  and  usually  takes  place  in  long-stand- 
ing cases,  but  in  cortical  veins,  if  cerebral  softening  occurs,  there  is  no 
tendency  to  circulatory  restoration. 

The  symptoms  of  marantic  thrombosis  are  those  of  venous  stasis, 
localized  edema,  and  disturbed  brain-function  following  upon  exhausting 
diseases.  As  the  longitudinal  sinus  is  usually  aifected  there  is  often 
epistaxis  and  disturbance  in  the  leg-centers,  indicated  by  weakness, 
tremors,  paralyses,  and  spasms  in  the  lower  extremities.  Convul- 
sions in  children  are  commonly  encountered,  and  may  be  limited 
or  monoplegic  when  a  cortical  vein  is  invaded.  Meningeal  irri- 
tation often  shows  itself  in  rigidities,  retracted  neck,  and  vasomotor 
disturbance. 

The  diag-nosis  of  marantic  thrombosis  is  usually  obscured  by  the 
overshadowing  picture  of  the  preceding  illness,  and  in  those  cases  where 
external  edema  does  not  point  the  way  it  is  rarely  deciphered  during 
life.  There  can  be  little  doubt  that  it  furnishes  some  of  the  cases  of 
cerebral  palsy  in  childhood.  Convulsions  coming  on  late  in  the  history 
of  exhausting  illness,  especially  in  children,  should  direct  attention  to 


228  DISEASES  OF  THE  BRAIN  PROPER. 

the  possibility  of  sinus  occlusion.  If  meningeal  or  focal  symptoms  are 
present,  coupled  with  local  edema  about  the  eye  or  face,  over  the  vertex, 
in  the  mastoid  or  occipital  region,  a  diagnosis  may  be  made. 

The  prognosis  will  depend  upon  the  nature  of  the  initial  illness, 
the  probability  of  cortical  softening,  and  the  vital  jjrospects.  AYhen 
the  cachexia  or  exhausting  disease  can  be  controlled  and  life  maintained, 
the  tendency  to  resorption  of  the  clot  presents  a  favorable  outlook,  except 
for  the  softened  areas  of  brain-tissue.  AVhen  these  have  been  produced, 
permanent  disability  of  a  motor  or  mental  character,  or  both,  may  be 
expected.      The  treatment  is  that  of  the  general  condition. 

Infective  sinus  thrombosis,  inflammatory  thrombosis  or  secondary 
thrombosis,  is  the  result  of  the  invasion  of  pathogenic  infectious  organ- 
isms. It  is,  therefore,  a  secondary  process  and  occurs  usually  in  adults. 
Generally  it  is  located  in  one  of  the  paired  sinuses  and  in  the  one  nearest 
the  infection  atrium.  It  is  likely  to  produce  meningitis  or  give  rise  to 
cerebral  abscess,  or  both,  and  it  is  frequently  attended  or  followed  by 
systemic  infection  and  pyemia.  It  arises  from  septic  traumatic  condi- 
tions of  the  face,  scalp,  cranial  and  facial  bones,  and  from  septic  pro- 
cesses in  the  nose,  mouth,  pharynx,  in  the  various  bony  sinuses,  and  in 
the  middle  ear  and  mastoid  process.  By  far  the  most  common  source 
of  infection  is  suppurative  middle-ear  disease.  Anthrax  of  the  face  and 
lips,  facial  and  scalp  erysipelas,  dental  caries,  and  carbuncles  have  l^een 
noted  as  causes.  Tlie  sinus  always  becomes  infected  by  extension  of  the 
septic  process  to  it,  either  by  direct  invasion  or  by  propagation  along  a 
venous  tributary.  Inflammation  of  the  sinus-walls  is  followed  by 
thrombotic  coagulation  of  the  contained  blood,  and  a  septic  plug  is 
formed  that  closely  adheres  to  the  diseased  and  softened  vessel. 

The  septic,  soft,  and  disintegrating  thrombotic  clot,  swarming  with 
pathogenic  and  pyogenic  bacteria,  sets  up  infection  of  the  immediate 
territory,  and,  yielding  particles  to  the  blood-stream,  often  induces  dissem- 
inated and  systemic  infection.  Thus  arise  the  numerous  pvogenic  foci 
throughout  the  body  that  are  frequently  present.  The  thrombus  once 
formed  is  prone  to  extend,  and  the  internal  jugular  is  often  invaded,  pre- 
senting itself  in  its  upper  third  as  an  indurated  cord  that  can  be  palpated 
in  the  neck.  Even  the  superior  vena  cava  has  been  invaded.  The 
sinus-walls  being  softened,  the  neighboring  leptomeninges  are  infected 
and  a  localized  or  disseminated  septic  meningitis  is  added.  In  a  similar 
way  the  infective  process  travels  along  the  veins  into  the  substance 
of  the  encephalon  and  sets  up  abscesses.  Macewen  thus  tabulates 
the  principal  differences  between  marantic  and  infective  sinus  throm- 
bosis : 

Sinus  Thrombosis. 
Makaxtic.  Ixfective. 

1.  Chiefly   affects   the  longitudinal   si-        1.   Chieflj' affects  the  paired  sinuses. 

nuses. 

2.  The  clots  tend  to  organization  or  are        2.  Clots  tend  to  j^urulent  disintegration. 

absorbed. 

3.  Hemorrhages  into  cerebral  cortex  in        3.  Hemorrhages  into  brain  or  cerebel- 

about  half  the  cases.  lum  seldom  occur. 


DISEASES   OF   THE   CEREBRAL    VEINS  AND  SINUSES.  229 

4.  Tendency  to  produce  brain  softening.         4.   No  tendency  to  brain  softening. 

5.  There  is  seldom  purulent  infection  as         5.  Purulent    infection    couamon     from 

a  sequence.  septic  or  infective  emboli. 

6.  No    accompanying    leptomeningitis,         6.  Often  coincident  purulent  leptomen- 

cerebral  or  cerebellar  abscess.  ingitis,   cerebral  or   cerebellar   ab- 

scess. 

The  symptoms  of  infective  sinus  thrombosis  are  local  and  sys- 
temic. The  local  ones  are  due  to  circulatory  disturbance,  such  as  cir- 
cumscribed edema  and  brain  symptoms.  They  will  be  given  in  detail 
in  the  description  of  thrombosis  of  special  sinuses.  The  systemic 
symptoms  are  those  of  septicemia ;  intense  headache,  often  localized  at 
the  seat  of  disease  ;  vomiting,  fluctuating  and  remittent  temperature  ; 
small,  thready  pulse  ;  rigors,  profuse  perspiration,  dry  tongue,  anorexia 
and  diarrhea,  or  constipation. 

Depending  upon  the  preponderance  of  symptoms  and  their  grouping, 
the  septicemia  shows  different  clinical  varieties.  When  the  lungs  are  first 
or  mainly  involved  by  the  plugging  of  pulmonary  vessels,  localized  or 
diffuse  pain  is  occasioned,  cough  is  induced,  and  the  expectoration  may 
change  to  "prune-juice"  appearance,  and  then  becomes  purulent,  fetid, 
and  extremely  oifensive  as  the  pulmonary  process  increases.  Abscesses 
form  and  gangrene  occurs.  In  this  way  septic  pneumonia  also  is 
induced. 

When  the  brunt  of  the  attack  falls  upon  the  abdominal  organs,  the 
typhoid  type  of  septicemia,  which  closely  mimics  enteric  fever  and  is 
sometimes  mistaken  for  it,  is  presented.  In  another  and  much  smaller 
group  of  cases  meningeal  symptoms  dominate  the  picture  and  are 
actually  due,  in  large  part  at  least,  to  the  infective  leptomeningitis. 
All  three  of  the  symptom  groups,  or  any  combination  of  their  various 
features,  may  be  presented  by  the  same  case. 

Infective  cavernous  sinus  thrombosis  arises  from  septic  invasion, 
reaching  the  sinus  usually  by  way  of  the  ophthalmic  vein.  It  may  also 
be  due  to  a  forward  extension  of  a  septic  process  in  the  lateral  or  petrosal 
sinuses.  The  secondary  meningitis  to  which  it  gives  rise  is  basilar. 
Fractures  of  the  cranial  base  and  blows  on  the  head  have  furnished  its 
starting-point.  Erysipelas  of  the  face,  especially  about  the  eye  and 
nose ;  abscess  of  the  orbit ;  infections  of  the  nasal,  buccal,  and  pharyn- 
geal cavities  or  of  their  sinuses  ;  ulceration  of  the  tonsillar  glands,  and 
caries  or  periosteitis  of  the  facial,  especially  of  the  maxillary  bones,  have 
led  to  it. 

Symptoms :  One  sinus  is  usually  first  involved,  and  the  local 
manifestations  are  one-sided.  There  is,  however,  a  pronounced  ten- 
dency for  the  process  to  invade  the  opposite  sinus,  and  then  the  case 
presents  bilateral  signs.  Such  a  sequence  is  highly  diagnostic.  The 
first  aifected  side  may  even  show  improvement  through  the  establish- 
ment of  the  collateral  return  circulation  before  the  second  side  is 
invaded.  There  is  usually  considerable  pain  of  a  supra-  or  infra-orbital 
neuralgic  sort,  and  diffuse  headache.  Mental  symptoms  are  wanting, 
unless  meningitis  is  set  up,  and  then  delirium,  hebetude,  and  coma  may 
appear.     When  the  sinus  is  plugged  the  return  circulation  through  the 


230  DISEASES  OF  THE  BRAIN  PROPER. 

ophthalmic  veins  is  cut  off.  The  orbital  contents  become  edematous,  the 
ocular  globe  is  thrust  forward,  the  lids  are  swollen,  and  the  swelling  ex- 
tends to  the  nose,  brow,  and  cheek.  There  may  also  be  swelling  on  the 
same  side  of  the  pharynx.  The  optic  disc  is  congested  or  choked,  the 
retinal  veins  are  distended,  and  pressure  is  exerted  on  the  ocular  nerves 
that  enter  the  orbital  apex.  This  causes  more  or  less  ophthalmoplegia. 
The  third,  fourth,  sixth,  the  ophthalmic  division  of  the  fifth,  and  the 
optic  nerves  are  more  or  less  affected.  Ptosis,  strabismus,  pupillary 
stasis,  and  defective  vision  in  varying  degrees  are  thereby  added  to  the 
exophthalmos. 

The  invasion  may  be  abrupt  or  insidious  and  the  disease  may  last 
from  a  few  days  to  several  months,  but  infective  cases  are  practically 
fatal.  When  the  second  eye  is  involved,  it  usually  is  very  rapidly 
affected.  The  appearance  of  basilar  meningitis  and  the  development 
of  septicemia  add  immediate  gravity  to  the  already  serious  condition. 

Infective  lateral  sinus  thrombosis  is  the  form  most  frequently 
encountered.  Its  origin  is  nearly  always  in  a  septic  condition  of  the 
middle  ear.  The  petrosal  sinuses  and  the  internal  jugular  are  usually 
invaded.  It  is  commonly  encountered  in  young  adults,  and  is  rare  in  the 
two  extremes  of  age.  While  ordinarily  due  to  middle-ear  disease,  it  may 
arise  from  a  mouth  or  throat  infection  by  way  of  the  Eustachian  tube 
and  tympanum,  from  extension  of  thrombosis  in  other  sinuses,  from 
basilar  fractures  involving  the  petron,  and  from  infections  about  the 
occiput,  nucha,  and  mastoid. 

Symptoms :  The  lateral  sinus  is  usually  affected  from  a  chronic 
middle-ear  suppuration  v/hich  has  caused  more  or  less  erosion  of  the 
tympanic  bony  structure.  An  acute  process  may  cause  it,  but  this  is 
exceptional.  In  the  chronic  cases  of  purulent  otitis  media  it  is  a  con- 
stant menace.  Frequently  there  is  a  lessening  or  cessation  of  the 
ear-discharge,  pain  develops  in  the  ear,  and  headache  follows.  The 
fluctuating  temperature  mounts  up,  and  vomiting  and  rigors  indicate 
the  involvement  of  the  sinus  or  an  intracranial  extension.  Local  signs 
of  lateral  sinus  thrombosis  depend  on  the  obstruction  of  its  lumen  and 
the  location  or  extent  of  the  thrombus  and  phlebitis.  Occlusion  of  the 
sinus,  blocking  the  inlet  of  the  mastoid  vein,  gives  rise  to  a  circum- 
scribed edema  extending  from  the  auricle  over  the  mastoid.  Pain  on 
percussion  of  the  mastoid  is  present  only  when  the  bone  or  periosteum 
is  inflamed.  If  the  thrombosis  is  situated  lower  in  the  sinus  and  shuts 
off  the  condylar  veins,  through  which  the  superficial  circulation  of  the 
lateral  lower  occipital  region  drains,  a  brawny  hardness  and  edema  may 
be  made  out  in  the  upper  part  of  the  posterior  cervical  triangle.  Should 
the  phlebitis  extend  into  the  internal  jugular,  extreme  local  tenderness  is 
found  over  the  upper  portion  of  this  vessel  on  palpation,  or  may  be 
experienced  by  the  patient  in  swallowing.  The  head  is  usually  inclined 
to  the  affected  side  to  lessen  muscular  pressure  on  the  jugular.  When 
the  thrombosis  follows  down  into  the  jugular,  it  may  be  easily  palpated 
as  a  firm,  cord-like  structure.  Disintegration  of  the  thrombus  may 
cause  it  to  disappear  in  a  few  days.  The  lymphatic  glands  in  the  neck 
are  frequently  engorged  and  easily  palpable.     Gerhardt  has  pointed  out 


DISEASES  OF  THE   CEREBRAL    VEINS  AND   SINUSES.  231 

that  daring  inspiration  the  external  jugular  vein  on  the  afFected  side  is 
less  prominent.  This  is  due  to  the  occlusion  of  the  internal  jugular, 
which  allows  rapid  drainage  of  the  external  branch  into  the  common 
trunk.  If,  however,  the  thrombus  extends  into  the  common  trunk,  the 
external  vessel  is  then  engorged  and  more  prominent  than  on  the  sound 
side. 

If  the  inflammatory  thickening  at  the  jugular  foramen  is  sufficiently 
great,  it  involves,  by  extension  or  pressure,  the  cranial-nerve  trunks, 
which  make  their  exit  at  this  opening.  Pneumogastric,  spinal  accessory, 
and  glossopharyngeal  symptoms  are  then  produced.  Respiratory,  laryn- 
geal, cardiac,  and  vocal  disturbances  ;  difficulty  in  swallowing,  spasm 
or  paresis  in  the  sternomastoid  and  trapezius  point  to  this  condition. 
Abscesses  sometimes  form  in  the  neck,  under  the  sternomastoid  or  in  the 
nuchal  region. 

Almost  from  the  first  there  are  distinct  cerebral  symptoms.  The 
cephalalgia  is  attended  by  somnolence,  which  may  deepen  into  coma. 
Delirium  is  often  an  early  symptom.  Phlebitis  is  likely  to  extend  into 
ihe  temporosphenoidal  lobe  and  cerebellum,  giving  rise  to  diffiise  inflam- 
mation or  rapidly  producing  softening  and  abscesses.  At  the  seat  of 
the  sinus  thrombosis  the  softened  dural  wall  no  longer  protects  the  soft 
meninges,  and  a  localized  septic  meningitis,  with  a  tendency  to  become 
diffuse  is  occasioned.  Even  the  bone  under  the  sinus  is  eroded,  and  defi- 
nite discolorations  are  left,  both  on  the  cranial  wall  and  on  the  cerebral 
surface,  to  mark  the  site  of  the  sinus  disease. 

A  disease  presenting  so  many  complications  and  possibilities  neces- 
sarily lacks  clinical  uniformity.  While  lateral  sinus  thrombosis  is 
usually  confined  to  one  side,  it  may  propagate  itself  into  the  venous 
channels  of  the  opposite  side  and  infect  both  internal  jugulars.  The 
appearance  of  cerebritis,  meningitis,  or  intracranial  abscess  greatly 
reduces  the  life  chances.  Septicemia  is  particularly  likely  to  develop, 
with  its  own  serious  import.  The  virulence  of  the  infection,  however, 
seems  to  vary  between  wide  extremes.  Some  cases  run  a  rapid  course 
to  fatal  termination  in  four  to  seven  days,  others  last  weeks  and  months, 
and  exceptional  ones  may  recover.  The  gravity  of  the  disease  can  not 
well  be  overestimated. 

Infective  thrombosis  of  the  longitudinal  sinuses  is  extremely 
rare,  while  marantic  thrombosis  finds  its  most  common  location  in  these 
venous  passages  and  especially  in  the  superior  one.  Infectious  condi- 
tions in  the  nasal  vault,  in  the  scalp,  and  in  the  cranial  diploe  of  the  ver- 
tical region  are  capable  of  extension  to  the  superior  longitudinal  sinus. 
Phlebitis  may  then  extend  to  the  cortical  veins.  Occlusion  of  the  sinus 
leads  to  local  edema  in  the  scalp  and  probably  in  the  brain  also,  but  the 
collateral  circulation  obviates  any  serious  results  from  this  mechanical 
feature.  The  danger  lies  in  the  likeliliood  of  septic  cerebral  phlebitis 
and  septic  meningitis.  Usually  the  obtrusive  meningitic  features  pre- 
dominate, and  suggestions  of  cortical  phlebitis  and  even  of  abscess  for- 
mation are  obscured  or  overlooked. 

The  treatment  of  infective  cranial  sinus  thrombosis  is  primarily 
surgical.       The   infection   atrium   is   to    be  determined   and    rendered 


232  DISEASES  OF  THE  BRAIN  PROPER. 

thoroughly  aseptic.  Whenever  possible,  it  must  be  eradicated.  In  the 
case  of  the  cavernous  sinuses  little  more  can  be  done  by  the  surgeon, 
but  Dwight  and  Germain  ^  have  reported  one  instance  in  which  the 
cavernous  sinus  was  reached  surgically  with  immediate  improvement  in 
the  patient's  condition,  though  with  fatal  termination  ultimately.  A 
previous  case  by  Hartly  was  entirely  successful.  Aggressive  inter- 
ference is  allowable,  and  indicated  when  the  lateral  and  longitudinal 
sinuses  are  invaded.  Many  cases  of  lateral  sinus  thromboses  have 
probably  been  saved  by  prompt  and  radical  interference.  The  sinus 
has  been  opened,  the  infective  thrombus  removed,  and  abscesses  in  the 
temporal  lobe  and  in  the  cerebellum  drained.  Often  as  a  preliminary 
measure  the  mastoid  antrum  and  the  middle  ear  have  been  surgically 
dealt  with,  but  when  there  is  evidence  of  sinus  thrombosis  it  is  a  waste 
of  time  and  opportunity  to  stop  at  this  step. 

Local  applications  of  heat  and  cold  to  the  head  may  be  used,  and 
serve  sometimes  to  relieve  the  headache  and  modify  the  delirium.  In 
view  of  the  septic  nature  of  the  disease,  supportive  measures  are  emphat- 
ically indicated  from  the  first.  Against  the  septicemia  we  may  bring 
measures  to  bear  that  favor  elimination  by  the  skin,  bowels,  and 
kidneys.  The  administration  of  antiseptics,  such  as  the  salicyl  pre- 
parations and  the  mercurials,  are  of  doubtful  value,  but  are  strongly 
advised  by  many  and  should  not  be  omitted. 


CHAPTER   IX. 

CEREBRITIS,  ENCEPHALITIS,  AND  ABSCESS  OF  THE 

BRAIN. 

Inflammation  of  the  brain  proper  may  be  local  or  generalizedy 
acute  or  chronic. 

Acute  Localized  Cerebritis. — Etiology. — The  brain  is  subject  to 
inflammatory  processes  the  same  as  any  other  parenchymatous  organ, 
yet  generalized  cerebritis  is  rare,  and  only  recently  have  we  learned  to 
recognize  it.  Localized  acute  cerebritis,  on  the  other  hand,  occurs  with 
frequency,  but  is  practically,  if  not  invariably,  a  secondary  condition. 
Meningitis  always  entails  some  underlying  cerebritis.  A  circumscribed 
cerebritis  occurs  about  a  Jiemorrhagic  focus  or  spot  of  thrombotic  softening 
if  infection  is  added.  Without  the  additional  infection  such  as  is  fur- 
nished by  septic  endocarditis  or  other  infective  focus  the  zone  surround- 
ing a  cerebral  tumor,  hemorrhage,  or  area  of  softening  is  one  of  conges- 
tion, edema,  and  pressure  necrosis.  Blows  on  the  head  may  cause 
localized  meningitis  and  cerebritis  at  the  point  of  violence,  or  on  the 
opposite  side  of  the  head  by  the  action  of  contre  coup.  In  some  cases 
the  local  cerebritis  alone  follows,  and  this  may  only  affect  the  white 
matter  below  the  cortex.  Apparently  the  traumatism  favors  the  local 
action  of  bacteria  by  reducing  the  resistance  of  the  tissues,  as  proved 
1  "Boston  Med.  and  Surg.  Jour.,"  1902. 


CEREBRITIS,   ENCEPHALITIS,  AND  ABSCESS  OF  THE  BRAIN.      233 

by  Ehrnrootli  in  an  interesting  series  of  experiments.  ^  Cranial  frac- 
tures, punctured  wounds,  and  perhaps  severe  concussion  may  cause  it. 
Bone  disease,  septic  processes  in  the  diploe,  and  in  the  cranial  bony  and 
venous  sinuses,  may  lead  to  cerebral  inflammation  and  be  followed  by 
abscess.  Infection  of  the  brain  after  operations  sometimes  causes  a 
diffuse  cerebritis  that  may  involve  an  entire  hemisphere.  Hernia  cere- 
bri is  a  manifestation  of  a  septic  inflammatory  process.  Sunstroke,  heat- 
stroke, and  alcoholism  seem  capable  of  inducing  cerebritis,  or  at  least  so 
modifying  the  cerebral  nutrition  that  dementia  may  follow  and  sclerotic 
brain-tissue  be  found  postmortem.  To  Van  Giesen  we  owe  a  knowl- 
edge of  the  cellular  changes  following  insolation  and  their  probable  re- 
lation to  an  acute  auto-intoxication. 

In  certain  conditions  the  inflammation  falls  on  definite  cerebral  struc- 
tures. In  this  way  arise  the  clinical  symptom  groups  described  under 
the  terms  acute  jjolio-encephalitis  superior  and  acute  jjolio-encephcditis  in- 
ferior, when  the  cranial  nuclei  are  invaded  in  the  upper  or  lower  groups, 
furnishing  acute  nuclear  ophthalmoplegia  in  one  instance  and  acute  bul- 
bar palsy  in  the  other.  These  have  already  been  described  with  the 
diseases  of  the  cranial  nerves.  Striimpell  alleged  an  acute  inflammatory 
process  in  the  cellular  cortex,  especially  of  the  motor  regions,  analogous 
to  that  of  poliomyelitis  as  the  explanation  of  many  cases  of  cerebral  palsy 
in  children.  To  this  he  applied  the  term  polio-encephalitis,  a  name  given 
also  to  the  inflammations  of  cranial-nerve  nuclei,  making  an  additional 
adjective  necessary.  It  is,  therefore,  sometimes  called  polio-encephalitis 
anterior  or  corticalis.  There  is  little  pathological  evidence  of  this  form 
of  cerebritis,  and  the  clinical  manifestations  of  the  attack  are  consistent 
with  the  idea  of  a  vascular  lesion.  As  there  is  a  growing  belief  in  the 
vascular  origin  of  poliomyelitis,  the  analogy,  if  not  the  identity,  of  the 
process  is  still  maintained,  and  probably  it  is  associated  with  an  acute 
arteritis  of  an  infectious  sort  in  both  instances.  Eeymond  ^  reports 
what  appears  to  be  a  typical  case  in  a  child  of  seventeen  months.  The 
microscopical  changes  were  certainly  of  inflammatory  origin  and  the 
disease  was  not  limited  to  the  motor  fields. 

The  patholog-ical  anatomy  of  the  various  conditions  which  have 
been  assembled  under  the  head  of  acute  localized  cerebritis  shows  at  first 
a  high  degree  of  vascular  engorgement,  edema,  and  punctate  hemorrhage. 
The  inflamed  tissue  presents  above  the  level  of  the  surrounding  part, 
and  is  often  slightly  softened.  Its  reddish  color  and  yielding  consist- 
ency have  led  to  its  description  as  a  red  softening.  It  has  much  the 
macroscopical  appearance  of  embolic  red  softening,  with  which  it  was 
long  confused.  Leukocytal  infiltration  of  the  brain  and  the  disintegra- 
tion of  neuroglia,  myelin,  and  nerve-cells  may  induce  a  pultaceous  and 
even  creamy  consistency.  A  nidus  ripe  for  infection  is  formed,  and  when 
this  occurs  abscess  formation  is  prompt.  Later  on,  if  not  infected,  there 
is  usually  more  or  less  shrinking  of  the  inflamed  mass,  absorption  of  the 
necrosed  elements,  proliferation  of  the  connective  tissue,  and  sclerotic 
thickening  which  may  reach  a  leathery  toughness.  Small  foci  may  in 
this  way  become  cicatrized.     Finally,  after  years,  it  may  be  impossible 

1  "  Rev.  Neurolog.,"  Aug.,  1900. 

2  "  Jahrb.  f.  Kinderheilk.,"  Bd.  xliv. 


234  DISEASES  OF  THE  BRAIN  PROPER. 

to  say  whether  inflanimation,  hemorrhage,  or  thrombosis  was  the  initial 
feature  of  the  cerebral  defect. 

Symptoms. — The  indications  of  acute  localized  cerebritis  are 
obscure.  Often  associated  conditions,  such  as  meningitis,  overshadow 
it  in  the  clinic.  Whatever  be  the  seat  of  the  cerebral  inflammation, 
there  is  usually  headache,  sometimes  vomiting,  and  rarely  optic  neuritis. 
Delirium  and  somnolence  may  be  present.  Involvement  of  special 
sensory  or  motor  convolutions  or  pathways  gives  rise  to  localizing 
features  marked  by  defect  or  disturbance  of  functioii.  The  clinical 
picture,  therefore,  always  strongly  suggests  meningitis,  and  the  treatment 
and  j)>'ognosis  are  practically  the  same  as  in  that  condition. 

Acute  Hemorrhagic  Encephalitis. — Striimpell,  in  1889,  and 
shortly  afterwTird  Leichtenstein,  in  1890,  called  attention  to  cases  of 
diffuse  hemorrhagic  encephalitis.  In  1895  Oppenheim  '■  reviewed  the 
literature  of  the  subject,  pointed  out  the  intimate  relation  of  the  disease 
to  Wernicke's  polio-encephalitis  superior  and  to  Striimpell's  polio-en- 
cephalitis anterior,  and  added  six  cases,  several  of  which  recovered. 
Other  cases  have  been  reported  by  Fiirbringer,  Putnam,  Freyhan, 
Neuwerk,  and  Brie,  all  of  which  are  quoted  by  Putnam.  ^  Brie  ^ 
has  since  reported  a  second  instance,  with  full  autopsy  and  bacteriolog- 
ical investigation.  There  can  be  little  doubt  that  numerous  cases  have 
been  mistaken  for  meningitis.  Anatomically  the  disease  is  marked  by 
multiple,  non-suppurative,  inflammatory  foci  showing  congestion  and 
punctate  or  massive  hemorrhages,  leukocytal  infiltration,  and  localized 
destruction  of  brain-tissue. 

Etiology. — Regarding  the  causation  of  acute  hemorrhagic  encepha- 
litis there  is  much  to  be  discovered.  Most  of  the  reported  cases  followed 
influenza.  Putnam's  last  case  followed  the  mumps,  and  erysipelas, 
diphtheria,  typhoid,  typhus,  and  malaria  ^  have  been  followed  by  localized 
hemorrhagic  encephalitis.  The  writer  has  seen  two  cases  after  in- 
fluenza, one  after  pneumonia,  and  one  with  some  unknown  infection 
associated  with  acute  nephritis.  It  is  a  matter  of  speculation  whether 
various  infections  act  locally  or  by  their  elaborated  toxins.  An  interval, 
a  sort  of  incubation  period,  is  often  noted  between  the  infectious  disease 
and  the  manifestation  of  the  cerebral  symptoms.  Children  and  young 
adults  furnish  most  cases. 

Morbid  Anatomy. — The  meninges  commonly  are  normal  in  appear- 
ance. There  is  usually  some  increase  of  cerebral  fluid,  and  the  ventricles 
may  be  largely  distended  by  blood-tinged  contents.  The  choroid  plexuses 
and  the  vessels  generally  are  engorged.  Scattered  throughout  the  brain, 
but  principally  in  the  white  matter  of  the  hemispheres  and  in  or  about 
the  basal  ganglia,  are  foci  of  hemorrhagic,  softened,  infiltrated  brain- 
tissue.  In  some  instances  the  hemorrhage  is  massive,  in  others  there  is 
but  a  slight  hemic  coloring.  Microscopically  the  blood-vessels  are 
found  distended,  the  lymphatics  filled  with  blood-cells  and  leukocytal 
elements,  and  at  various  points  they  are  ruptured  into  the  surrounding 
brain-substance. 

1  "Deut.  Zeit.  f.  Nervenheilk.,"  Band  vi. 

2  "Jour.  Nerv.  and  Ment.  Dis.,"  Jan.,  1897.       *  "Neurol.  Centralbl.,"  No.  1,  1897. 
4 Dana,  "Medical  Eeeord,"  July  7,  1900. 


CEEEBBITIS,  ENCEPHALITIS,  AND  ABSCESS  OF  THE  BRAIN.      235 

The  influenza  bacillus  has  been  found  iu  these  fbci,^  and  tiiere  are 
some  who  think  the  process  may  originate  in  bacterial  embolism. 

Symptoms. — The  symptoms  of  acute  primary  hemorrhagic  enceph- 
alitis are  not  definite,  and  commonly  suggest  meningitis.  A  preceding 
acute  infection  may  be  followed  immediately  or  after  several  weeks  by 
headache,  hebetude,  vomiting,  convulsions,  or  localized  palsies.  Slug- 
gish pupils  and  squints  are  rather  common.  Sleepiness  that  tends  to 
coma  is  usual,  and  rigidity  of  the  neck  has  been  repeatedly  observed. 
The  pulse  may  be  slow,  the  temperature  elevated,  normal,  or  subnormal. 
Tlie  palsies,  which  may  be  multiple,  declare  the  localized  processes 
and  have  a  tendency  to  vary  in  intensity  fi-om  day  to  day.  Pulse  and 
respiration  become  shallow  and  frequent,  the  stupor  deepens,  bedsore 
may  form,  and  death  terminate  the  case  in  a  few  days  or  in  several 
weeks.  A  fair  proportion  of  cases,  as  insisted  upon  by  Oppenheim  and 
others,  recover,  almost,  if  not  completely,  after  a  tardy  and  anxious 
convalescence. 

It  will  be  seen  that  the  disease  is  clinically  obscure  and  the  diagnosis 
has  usually  been  made  post  mortem.  During  life  it  is  usually  confounded 
with  meningitis.  This  is  not  of  great  practical  moment,  as  the  treatment 
is  the  same.  The  prognosis  is  grave,  but  rather  more  favorable  than  the 
early  descriptions  indicated.  Gradual  onset,  comparative  mildness  of 
symptoms,  and  long  duration  of  disease  have  a  favorable  import. 

Chronic  cerebritis,  and  chronic  encephalitis  are  terms  loosely  applied 
to  late  and  usually  secondary  conditions  that  are  mainly  sclerotic  and 
degenerative  in  nature.  This  sclerosis  may  exist  in  disseminated 
patches  or  in  large,  circumscribe^d  areas  ;  it  may  involve  an  entire  hemi- 
sphere or  be  largely  confined  to  the  gray  matter  of  both  half-brains. 
The  portion  of  the  encephalon  thus  affected  is  disturbed  in  its  function, 
which  is  usually  greatly  impaired  or  entirely  abolished. 

Abscess  of  the  Brain. — Brain- abscess  is  always  secondary,  and  is 
due  to  the  invasion  of  pyogenic  bacteria. 

Etiolog-y. — In  a  rough  way  we  may  say  that  all  the  causes  of  infect- 
ive sinus  thrombosis  and  acute  localized  cerehrit'ts  are  competent  to  pro- 
duce brain-abscess,  as  the  first  step  in  its  development  is  inflammation. 
Suppurative  middle-ear  disease  furnishes  almost  two-fifths  of  the  cases, 
and  head  injury  about  one-fourth.  About  one-sixth  of  the  cases  are 
due  to  general  pyemic  states.  Of  this  number  purulent  pulmonary 
diseases  fui'nish  the  great  majority.  Septic  inflammation  in  the  nasal 
and  pharyngeal  spaces,  brain-tumors,  infected  cerebral  hemorrhages, 
and  infarcts  furnish  a,  small  contingent.  In  rare  cases  the  oi'dium  albi- 
cans has  been  found  in  the  abscess  and  traced  througli  the  blood-vessels 
into  the  nose.  In  others  the  only  pathogenic  bacterium  present  is  the 
tubercle  bacillus.  Actinomyces  have  also  been  encountered.  Males 
are  about  three  times  as  subject  to  abscess  of  the  brain  as  females,  and 
five  times  as  frequently  affected  with  the  traumatic  variety.  More  than 
half  of  the  cases  occur  between  ten  and  thirty  years  of  age.  Koerner 
states  that  in  Prussia  about  five  per  cent,  of  all  deaths  between  the  ages 
of  ten  and  twenty  are  due  to  cerebral  complications  of  otitis,  mainly 
abscesses. 

^  Putnam,  loc.  cit. 


236  DISEASES  OF  THE  BRAIN  PROPER. 

Pathological  Anatomy. — The  most  common  seat  of  brain-abscess 
is  in  the  temporosphenoidal  lobe,  due,  doubtless,  to  the  relation  of  the 
venous  circulation  of  this  part  of  the  brain  and  of  the  middle  ear  with 
the  petrosal  sinuses.  In  decreasing  frequency  follow  the  cerebellum, 
the  centrum  ovale,  the  pons,  the  occipital  lobes,  the  parietal  lobes,  and 
the  frontal  lobes.  The  invasion  pathway  is  often  obscure,  but  the  arterial 
route  has  been  demonstrated  in  some  instances,  the  perivascular  spaces 
in  others.  The  common  sequential  relation  of  middle-ear  disease,  sinus 
thrombosis,  and  brain-abscess  calls  attention  at  once  to  the  venous  chan- 
nels as  entrv-way  for  the  pyogenic  bacteria.  The  extension  of  cere- 
bral phlebitis  from  a  sinus  thrombosis  was  repeatedly  mentioned  in  the 
preceding  chapter  as  inducing  cerebral  softening  and  abscess  formation. 
Frequently  the  abscess  is  single  and  of  a  size  varying  from  a  pea  to  a 
hen's  egg  or  even  to  a  larger  size.  In  the  regions  of  latent  lesions, 
especially  in  the  frontal  and  occipital  lobes,  an  abscess  may  attain  very 
large  dimensions  and  contain  many  ounces  of  pus.  Very  commonly 
riiidtiple  brain-abscesses  are  encountered.  In  ear  disease,  abscesses,  both 
above  and  below  the  cerebellar  tentorium,  are  generally  encountered, 
and  failure  to  explore  the  cerebellum  after  the  evacuation  of  an  abscess 
in  the  temporal  lobe  has  lost  lives.  When  the  infection  arises  from 
purulent  lung  disease  or  septic  endocarditis,  the  left  side  of  the  brain  is 
more  aifected  for  the  same  reason  that  embolism  favors  the  left  hemi- 
sphere. Under  these  circumstances,  and  in  the  case  of  infection  from 
typhus,  enteric  fever,  and  other  general  pyemic  states,  numerous  small 
abscesses  may  be  found.  In  this  way  the  brain  may  be  fairly  riddled 
with  multiple  abscesses.  Relatively  the  gray  matter  of  the  brain  is  less 
liable  to  abscess  formation  than  the  white  substance,  and  the  cortex  is 
often  preserved  over  an  extensive  underlying  abscess.  Harely  a  fistulous 
tract  communicates  with  diseased  bone,  or  reaches  the  outer  surface  of 
the  cranium,  or  discharges  into  the  nasal  fossse.  On  the  other  hand,  no 
connection  may  be  discernible  between  the  infection  and  the  abscess. 
The  pus  varies  with  the  nature  of  the  infection  and  the  age  and  char- 
acter of  the  abscess.  In  some  recent  cases  it  merely  saturates  the  soft- 
ened tissues  ;  in  others  it  is  encysted ;  in  a  third  variety  an  encysted 
old  abscess  is  found  floating  in  a  secondary,  surrounding,  more  recent 
abscess,  the  walls  of  which  are  made  up  of  infiltrated,  purulent,  softened 
brain-tissue.  In  the  old  cases  the  pus  is  thick,  yellowish  or  greenish, 
and  in  about  a  third  of  them  extremely  fetid  and  offensive.  Some- 
times it  is  reddish  from  the  admixture  of  blood.  The  pus-corj)usc]es 
and  leukocytal  elements  vary  according  to  the  age  of  the  lesion.  The 
streptococcus  is  usually  found,  but  pneumococcus,  staphylococcus, 
bacillus  pyocyaneus,  bacillus  tuberculosis,  and  the  bacteria  of  various 
mixed  infections  have  been  noted. 

The  majority  of  abscesses  are  eiicysted.  When  located  near  the 
surface,  the  meninges  may  form  part  of  the  containing  wall.  A  begin- 
ning cyst-wall  has  been  noted  as  early  as  the  thirteenth  day.  Its 
thickness  and  consistency  increase  with  age.  It  is  made  up  by  a  pro- 
liferation of  the  neuroglial  tissue  and  the  fibrous  structures  of  the 
brain.     Usually  delicate,  in  some  instances  it  forms  a  glistening,  resist- 


CEREBRITIS,  ENCEPHALITIS,  AND  ABSCESS  OE  THE  BRAIN.     237 

iiiL!:  iiu'inhfiinc  of  almost  a  liorny  coiisistoney,  and  it  may  even  calcify. 
The  l)rain-tissue  surrounding  an  abscess  is  usually  more  or  less  softened, 
and  if  infected  rapidly  breaks  down,  leavino;  the  old  abscess-cyst  afloat. 
Ilu})ture  of  an  abscess  by  its  steadily  increasing  contents,  which  is  the 
usual  ultimate  accident,  inundates  the  brain-tissue  or  breaks  into  the 
meninges,  setting  up  a  purulent  process,  or  floods  the  ventricles  and 
promptly  terminates  life. 

Symptoms. — The  symptoms  of  brain-abscess  are  usually  indefinite, 
often  very  obscure,  and  sometimes  entirely  unnoticed  by  patient  and 
physician.  Different  cases  present  the  widest  variety  of  clinical  phases, 
depending  upon  the  virulence  of  the  infection,  the  rapidity  of  abscess 
growth,  the  location  of  the  process,  and  the  complications.  Some  cases 
run  a  rapid  course  to  a  fatal  termination  in  a  few  days,  and  others  pre- 
sent a  latent  period  that  may  last  months  and  even  years,  to  end  with 
rupture  and  death.  We  may,  in  some  cases,  make  out  tkree  stages^ — one 
of  invasion,  one  of  remission,  and  a  terminal  one  of  paralytic  features. 
In  other  words,  one  of  cerebritis,  one  of  encapsulation  and  latency,  and 
one  of  rupture,  infection,  meningitis,  or  ventricular  inundation,  and 
death. 

The  invasion  stage  jjresents  the  obscure  picture  of  encephalitis. 
There  is  a  low  febrile  movement  marked  by  a  vacillating  temperature, 
which  sometimes  has  a  distinctly  subnormal  tendency,  with  a  slow  pulse. 
An  intense  and  persistent  headache  lasting  days,  taken  with  the  tem- 
perature, suggests  meningitis.  The  headache  is  often  circumscribed  and 
may  correspond  to  the  location  of  the  abscess,  but  as  frequently  is  felt 
at  a  distant  point.  Rigors  and  profuse  sweats  indicate  the  septic  char- 
acter of  the  disease.  Vomiting  and  constipation  or  diarrhea  are  often 
present.  Papillitis  or  optic  neuritis  only  rarely  occurs.  The  mental 
state  is  one  of  torpor  and  indifi^erence,  or  delirium  may  be  present  and 
the  sharp  "  hydrocephalic  "  cry  may  be  nttered.  This  stage  lasts  from 
two  to  ten  days  and  may  pass  at  once  into  the  third  stage  or  be  followed 
by  a  remission. 

The  remission  stage  is  gradually  established  by  the  subsidence  of  the 
disturbances  that  appear  in  the  period  of  invasion.  The  headache, 
fever,  vomiting,  and  mental  irritation  almost  disappear  or  entirely  cease. 
Occasionally  the  improvement  is  very  prompt  and  complete.  A  latent 
period  is  thus  produced  that  may  extend  almost  indefinitely.  The 
gradual  increase  in  the  size  of  the  abscess  and  its  encapsulation  gives 
rise  to  very  little  disturbance.  Its  effect  is  that  of  a  foreign  body,  and 
its  presence  is  marked  by  much  less  disturbance  than  attends  the  growth 
of  a  solid  tumor.  At  times  there  may  be  intense  headache,  vomiting, 
and  even  convulsions.  An  occasional  temperature,  or  a  tendency  to  a 
remitting  temperature,  sweats,  and  emaciation  may  show  the  hectic  state 
and  alone  indicate  the  ever-present  danger. 

The  ■paralytic  stage  is  the  usual  termination  of  brain-abscesses  that 
have  presented  a  period  of  latency  or  remission.  It  is  of  sudden  onset, 
and  rapidly  runs  its  course  within  a  few  days.  It  not  infrequently 
promptly  follows  the  invasion  period,  and  the  fatal  mechanism  is 
usually  the  same  in  both.     In  some  cases  this  consists  of  a  rupture  of  the 


238  DISEASES  OF  THE  BRAIN  PROPER. 

abscess,  causing  a  rapid  infiltration  of  the  cerebral  capsule  ;  an  invasion 
of  the  medulla ;  a  tearing  through  the  cortex,  setting  up  a  purulent  men- 
ingitis; or  the  inundation  of  the  ventricles.  There  remain,  however, 
a  large  number  of  cases  in  which  these  anatomical  conditions  are  want- 
ing to  explain  the  sudden  onset  of  this  stage.  Ordinarily  an  apoplectic 
stroke,  with  or  without  convulsions,  takes  place.  Usually  there  are  no 
premonitions  or  only  the  vague  indications  of  cerebral  mischief  which 
have  presented  at  intervals  during  the  latent  period.  The  apoplectic 
coma  may  be  punctuated  by  Jacksonian  fits,  marked  by  conjugate  devia- 
tion of  head  and  eyes  and  some  lateral  weakness,  and  the  patient  may 
succumb  in  a  few  hours  without  regaining  consciousness.  Death, 
indeed,  may  be  sudden.  If  the  immediate  effects  of  the  stroke  subside, 
a  hemiplegia  with  marked  rigidity,  and  often  with  spasmodic  features, 
is  progressively  developed.  The  headache,  the  fever,  and  the  symptoms 
of  the  early  stage  reappear  or  become  intensified.  Nystagmus,  pupillary 
inequalities,  and  involvement  of  the  ocular  muscles  appear  and  death 
is  likely  to  follow,  preceded  by  delirium  and  coma. 

The  localizing  symptoms  of  brain-abscess  are  rarely  prominent. 
Usually  they  are  quite  indefinite  or  entirely  lacking.  The  location  is 
often  in  the  frontal,  temporal,  and  occipital  lobes,  or  in  a  cerebellar 
hemisphere,  whence  focal  symptoms  do  not  arise.  As  a  rule,  an  abscess 
of  the  brain,  due  to  disease  of  the  cranial  bones,  lies  subjacent  to  the 
original  lesion.  In  the  same  way  ear  disease  gives  rise  to  abscess  near 
the  petron,  but  in  rare  instances  the  purulent  collection  has  been  found 
at  a  considerable  distance,  and  even  in  the  opposite  half  of  the  brain. 
Abscess  due  to  embolic  process  from  the  heart  or  lungs  is  likely  to  be 
located  in  the  capsular  or  Sylvian  arteries,  and  gives  rise  to  early  hemi- 
plegic  features  or  disturbances  of  the  motor  cortex.  The  circumscribed 
headache  sometimes  furnishes  a  localizing  feature,  but  it  can  not  be 
relied  upon.  Macewen  has  noted  a  higher  percussion  note  over  the 
abscess  than  was  yielded  by  the  rest  of  the  head,  and  Dana  has  con- 
firmed this  symptom  in  one  case.  Local  tenderness  and  increased 
temperature  may  occasionally  be  made  out.  When  the  abscess  is  asso- 
ciated with  septic  sinus  thrombosis,  we  have,  in  addition,  the  local  super- 
ficial evidence  of  that  disease.  Even  when  the  sensorimotor  zone  is 
invaded,  the  symptoms  may  be  very  slight.  Abscesses  may,  however, 
yield  as  definite  localizing  features  as  any  other  encephalic  lesion,  and 
these  then  have  the  significance  and  value  discussed  under  the  head  of 
Cerebral  Localization.  Involvement  of  cranial  nerve-trunks,  cerebellar 
symptoms,  hemianopsia,  Jacksonian  fits,  aphasias,  and  other  localizing 
indications  should  always  be  carefully  sought.  Multiple  abscesses  also 
lead  to  symptoms  of  corresponding  diversity. 

Diag-nosis. — The  diagnosis  of  cerebral  abscess  depends  very  largely 
upon  the  history  or  presence  of  trauma  or  of  an  infective  condition  about 
the  head  and  face  or  in  the  thorax.  A  chronic  otorrhea,  maxillary  ab- 
scess, ozena,  sinus  suppuration,  or  purulent  pulmonary  disease,  followed 
by  headache,  vomiting,  delirium,  stupor,  slow  pulse,  vacillating  tempera- 
ture, and  rigors,  means  encephalic  invasion.  These  symptoms  are 
common  to  meningitis  and  abscess,  and  the  differential  diagnosis  can  not 


CEREBEITIS,  ENCEPHALITIS,  AXD  ABSCESS  OF  THE  BBAIN.      239 

always  be  made.  Any  evidence  of  a  circumscribed  process,  however, 
favors  the  idea  of  abscess,  and  hence  localizing  .symptoms  become  very 
important.  The  two  conditions  are  often  associated  and  a  terminal 
suppurative  meningitis  is  common  in  abscess.  In  latent  periods  the 
diiferentiation  of  cerebral  abscess  from  a  growth  may  be  impossible  ; 
nor  is  it  essential.  The  terminal  stage,  with  its  rapid  onset  and  para- 
lytic features,  may  readily  be  confounded  with  cerebral  hemorrhage  or 
softening  if  it  occurs  in  middle  life  and  is  preceded  by  apparent  health. 
AVhen  systemic  sepsis  is  manifested,  the  purulent  character  of  the  en- 
cephalic process  is  less  doubtful. 

Abscesses  resulting  from  ear  disease,  bone  disease,  and  disease  about 
and  in  the  facial  cavities — in  other  words,  abscesses  due  to  direct  invasion 
— are  ordinarily  single.  Abscesses  resulting  from  pyemic  states  and  from 
purulent  thoracic  conditions  are  usually  multiple.  Cerebellar  abscesses 
are  also  usually  multiple.  The  localizing  diagnosis  is  made  on  the  lines 
already  laid  down  in  chapters  iii  and  iv  of  this  part. 

Prognosis  and  Treatment. — Suppurative  disease  within  the 
cranium  is  always  grave.  Although  a  cerebral  abscess  may  encapsulate 
and  lie  dormant  for  years,  this  can  not  reasonably  be  expected  to  take 
place,  and  even  when  it  does,  it  constitutes  a  constant  menace  to  life. 
Encapsulation  does  not  necessarily  check  suppuration,  and  eventual  rup- 
ture or  secondary  infection  is  the  legitimate  sequel.  The  late  results 
are  ordinarily  fatal,  and  latent  cerebral  abscesses  account  for  a  certain 
proportion  of  sudden  deaths. 

The  treatment  of  cerebral  abscess  should  be  prophylactic.  Chronic 
suppurations  in  ear  and  nose  should  never  be  neglected  and  the  utmost 
precautions  should  be  taken,  in  the  management  of  all  wounds  about  the 
head  and  face,  to  prevent  infection  and  sepsis.  From  these  largely 
controllable  sources  the  great  majority  of  brain-abscesses  and  other  en- 
docranial  suppurations  arise.  When  the  diagnosis  is  established,  there 
should  be  immediate  recourse  to  surgery.  Of  all  encephalic  diseases 
abscess  promises  the  best  results  to  surgical  measures.  Adequate  drain- 
age after  opening  the  skull  has  been  followed  by  brilliant  success  in 
numerous  cases  and  in  the  hands  of  many  operators.  All  other  meas- 
ures are  inadequate. 


240  DISEASES  OF  THE  BRAIN  PROPER. 


CHAPTER   X. 
THE  CEREBRAL  PALSIES  OF  CHILDREN. 

A  NUMBEE  of  varied  developmental  and  acquired  cerebral  defects 
result  in  paralysis  in  childhood.  They  involve  or  destroy  within  the 
cranium  some  portion  of  the  upper  motor  neuron,  and  give  rise  to  clini- 
cal types  that  justify  a  separate  description.  Their  importance  and  fre- 
quency have  been  recognized  only  within  a  few  years,  but  it  is  now 
apjjreciated  that  in  the  early  years  of  life  cerebral  palsies  are  fully 
as  common  as  the  spinal  variety.  Etiologically,  they  may  be  divided 
into  three  groups  :  (1)  Those  due  to  prenatal  conditions;  (2)  those  fol- 
lowing birth  accidents,  and  (3)  those  dependent  upon  disease  or  trauma 
after  birth.  Clinically,  we  also  divide  them  into  those  showing  uni- 
lateral defects,  the  hemiplegic  cases,  and  those  presenting  bilateral 
defects,  the  diplegic  cases. 

Etiology. — One  of  the  most  important  prenatal  conditions  resulting 
in  infantile  cerebral  palsy  is  an  actual  deficiency  of  brain  elements,  a 
true  agenesis.  This  may  be  marked  by  convolutional  simplicity  and  a 
lessened  number  of  cortical  cells  and  pyramidal  fibers.  In  other  cases 
a  part  or  the  whole  of  a  hemisphere,  or  of  both  hemispheres,  may  be 
lacking.  Between  these  gross  teratological  defects  and  a  condition  in 
which  the  neuron  units  have  diminished  dynamical  qualities  or  a  less- 
ened power  of  endurance,  that  in  early  life  leads  to  their  atrophic  or 
sclerotic  degeneration  there  is  but  a  difference  of  degree.  The  lack  of 
constitutional  endurance,  of  capacity  for  growth,  and  of  resistive  power 
underlies  many  brain  and  cord  diseases  that  present  hereditary  and 
familial  characteristics.  In  other  instances  it  furnishes  a  lowered  re- 
sistance to  toxic  influences.  In  given  cases  unfinished  children,  lack- 
ing motor  elements  in  the  cortical  mantles,  and  children  born  prema- 
turely, before  the  pyramidal  apparatus  has  been  well  established,  present 
various  degrees  of  motor  and  cerebral  defect.  The  upper  motor  neuron 
is  well  formed  only  at  the  ninth  intra-uterine  month,  and  not  com- 
pletely developed  until  the  second  or  third  month  after  birth.  Much 
defect  in  the  upper  neuron  is  always  marked  by  spasticity  and  impaired 
motility  in  the  muscles  supplied  by  the  lower  and  terminal  motor 
neuron. 

Rarely  direct  traumatism  has  affected  the  brain  of  the  unborn  child, 
which  has  presented  hemiplegic  contractures  at  birth.  In  other  cases 
evidence  of  hemorrhage  and  softening  has  been  found,  and  in  many 
instances  the  probability  of  a  prenatal  meningo-encephalitis  has  been 
upheld  by  the  presence  of  localized  and  diffuse  sclerotic  changes  in  the 
brain  of  new-born  children.  Inherited  sypliilis  and  other  toxic  condi- 
tions due  to  illness  of  the  mother  have  been  accused  in  some  of  these 


THE  CEREBRAL   PALSIES  OF  CHILDREN.  241 

cases.  Porencephalia  is  usually  due  to  intrauterine  disease  of  the  cere- 
bral vessels. 

The  conditions  attending  birth  frequently  lead  to  brain-lesions 
in  the  child.  The  great  majority  of  cerebral  birth  palsies  occur 
in  protracted  labors,  and  consequently  in  priniiparse.  A  number  of 
them  follow  precipitate  labor  and  in  both  are  due  to  violent  compression 
of  the  fetal  head.  Comparatively  few  can  be  attributed  to  the  use  of 
forceps,  and  it  is  exactly  in  these  cases  that  the  labor  is  likely  to  have 
been  tedious.  Forceps  accidents,  however,  can  not  be  denied  or  over- 
looked, and  the  misuse  of  these  powerful  instruments  is  fraught  with 
serious  results  to  the  skull  and  brain  of  the  child.  The  facts,  however, 
favor  early  skilful  instrumental  interference  as  compared  with  tedious 
labor. 

The  frequency  of  hemorrhage  into  the  cerebral  and  spinal  meninges 
during  birtla  has  been  put  on  a  sound  foundation  by  the  investigations 
of  Litzmann,  ISIcXutt,  and  Spencer.  It  is  found  in  the  great  majority 
■of  stillborn  children  and  is  the  common  cause  of  asphyxia  of  the 
newborn.  Occasionally  this  blood  comes  from  a  ruptured  longitu- 
dinal sinus,  but  most  frequently  from  the  pial  vessels.  Punctate  and 
larger  hemorrhages  within  the  substance  of  the  brain  and  cord  are  fre- 
quent. The  results  of  these  birth  hemorrhages  depend  upon  the  quan- 
tity and  location  of  the  effused  blood.  Where  death  does  not  follow,  all 
degrees  of  disability  are  encountered.  Palsies  follow  the  involvement  of 
the  motor  cortex  or  its  pyramidal  tracts,  but  if  the  frontal  lobes  are  seri- 
ously affected,  idiocy  is  a  consequence  and  is  a  frequent  accompaniment  of 
motor  disturbance.  Similar  disturbance  of  the  latent  lesion  territories 
of  the  brain  may  give  rise  to  insignificant  or  very  obscure  symptoms. 
As  a  rule,  the  hemorrhage  is  basilar  in  location  in  vertex  presentations 
and  vertical  in  breech  cases.  The  absorption  and  organization  of  these 
hemorrhages  lead  to  a  more  or  less  difftise  sclerosis  of  the  brain-substance 
that  inhibits  its  growth  and  diminishes  its  functional  capacity.  In 
•other  cases  in  terminal  stages  large  areas  of  softening  and  cyst-like 
formations  are  found  that  are  indistinguishable  from  porencephalia. 
In  about  one-fourth  of  these  cerebral  birth  hemorrhages  the  spinal  cord 
is  similarly  affected.     Some  cases  of  syringomyelia  may  have  this  origin. 

The  postnatal  causes  of  cerebral  palsies  in  children,  according  to 
Osier's  list,  are  hemorrhages,  embolism,  endo-  and  peri-arterial  changes, 
encephalitis,  and  cerebral  venous  thrombosis.  In  other  words,  they  are 
the  same  as  in  adults,  and  hemorrhage  is  more  frequent  than  thrombosis. 
The  relation  of  acute  infectious  diseases  to  embolism  and  arteritis  only 
needs  to  be  recalled.  Traumatism  and  tumor  formation  cause  some 
•cases.  Of  encephalitis  much  has  been  said,  and  Strumpell  claimed 
cortical  polio-encephalitis  to  be  the  lesion  in  many  of  these  cases,  but 
the  exact  pathological  process  still  escapes  us  owing  to  the  paucity  of 
early  post-mortem  examinations.  It  is  just  as  likely  that  the  lesion  is 
primarily  vascular.  Gowers  was  the  first  to  insist  on  the  part  played 
by  venous  thrombosis,  and  others,  among  them  Osier,  have  added 
weight  to  the  contention.  This  cerebral  venous  thrombosis  is  often  a 
part  of  sinus  thrombosis,  to  which  it  may  hold  a  primary  or  secondary 
1(3 


242 


DISEASES  OF  THE  BRAIN  PROPER. 


relation.  It  serves  to  produce  softening,  and  sclerotic  changes  in  the 
cortex  and  palsies  follow.  As  many  of  these  palsies  start  with  convul- 
sions, the  question  arises  whether  the  convulsion  is  the  cause  or  eifect  of 
the  lesion.  It  may  be  either.  There  can  be  no  doubt  that  the  increased 
arterial  tension  of  the  convulsed  state  may  cause  rupture  of  cerebral 
vessels,  but,  as  a  rule,  the  convulsions  are  due  to  the  irritant  effect  of 
the  lesion.  Later  on  epileptic  or  epileptoid  convulsions  are  very  com- 
monly encountered.  Sex  plays  no  etiological  part.  Males  and  females 
are  about  equally  aifected.  One-half  the  postnatal  cases  in  children 
occur  within  the  first  three  years  of  life. 

Morbid  Anatomy. — The  post-mortem  findings  in  these  cases  furnish 
various  lesions.     Sachs  gives  the  following  table  : 


CLASSIFICATIOlSr  OF  INFANTILE  CeREBEAL  PALSIES. 


Groups. 

Morbid  Lesion. 

I.  Paralysis    of   intrauterine 
onset. 

Large  cerebral  defects,  porencephalia. 
Defective  development  of  pyramidal  tracts. 
Agenesis  corticalis,  highest  nerve-elements  involved. 

II.  Birth  palsies. 

Meningeal  hemorrhage,  rarely  intracerebral  hemor- 
rhage. 
Later  conditions  :   Meuingo-encephalitis  chronica, 
sclerosis  and  cysts,  partial  atrophies. 

III.  Acquired  palsies. 

Hemorrhage,  meningeal  and  rarely  cerebral. 

Thrombosis,  from  endarteritis,  and  in  marantic  con- 
ditions. 

Embolism. 

Later  conditions  :  Atrophy,  cysts,  and  diffuse  and 
lobar  sclerosis.     Meningitis   chronica.      Hydro- 
cephalus, seldom  the  sole   cause.     Primary  en- 
cephalitis, the  polio-encephalitis  corticalis  acuta 
of  Strumpell.  (?) 

The  difiiculty  of  deciding  the  origin  of  the  terminal  conditions  is 
very  great  and  it  is  often  impossible.  Porencephalia,  for  instance,  may 
be  due  to  defective  development,  to  embolism,  to  thrombosis,  or  to  hem- 
orrhage. The  initial  process  of  a  diffuse  sclerosis  may  be  hemorrhagic 
or  inflammatory. 

Symptoms. — The  clinical  history  of  cerebral  palsies  in  children 
varies  in  the  three  sets  of  cases.  In  the  prenatal  cases  the  condition  is 
congenital,  but  may  not  be  noticed  for  some  time  after  birth.  In  birth 
palsies  the  condition  is  usually  noticed  shortly  after  birth  or  develops 
within  a  few  weeks.  In  the  later-acquired  cases  the  patients  may  pre- 
sent an  ordinary  record  ujd  to  the  onset  of  the  paralytic  features.  In 
their  final  development  all  present  very  common  attributes  and  are 
usually  indistinguishable  by  external  examination  alone.  The  great 
majority  of  natal  and  prenatal  cases  have  bilateral  palsies.  After  birth 
the  tendency  is  to  one-sided  paralysis  and  after  the  age  of  three  it  is 
almost  the  invariable  form.  A  pure  monoplegia  is  so  extremely  un- 
common as  to  be  almost  unknown. 


THE  CEREBRAL   PALSIES  OF  CHILDREN.  243 

Hemipleg-ic  Cases. — The  hemiplcgic  cases  are  the  best  type  for 
study,  as  the  unaffected  side  furnishes  an  opportunity  for  comparison. 
Ordinarily  the  paralytic  features  develop  after  an  acute  febrile  attack^ 
after  or  during  an  acute  infectious  fever,  or  in  marantic  states.  The 
child  is  seized  with  convulsions,  which  are  more  severe  on  or  entirely 
confined  to  one  side  of  the  body  and  to  the  side  that  is  afterward  para- 
lytic. The  convulsive  attack  is  usually  prolonged,  lasting  for  several 
hours  or  even  for  a  day  or  two,  and  perhaps  returns  several  times 
within  a  few  days.  During  the  eclamptic  seizures  the  temperature 
may  be  markedly  elevated  and  more  or  less  unconsciousness  is  commonly 
present.  The  child  is  left  weak  and  exhausted,  often  with  continued 
feverishness,  and  the  loss  of  power  on  one  side  is  frequently  only 
incidentally  noticed.  If  the  child  had  formerly  spoken,  speech,  as 
a  rule,  is  temporarily  lost,  whether  the  paralysis  be  left-  or  right- 
sided,  but  after  the  age  of  about  six  years  aphasia  is  well  marked 
only  in  lesions  of  the  left  side  in  right-handed  children.  If  their 
intellectual  faculties  are  not  destroyed,  speech  even  then  is  regained 
with  surprising  rapidity. 

The  paralyzed  limbs  soon  develop  marked  spasticity  with  exaggerated 
reflexes,  which  the  spasticity  may  conceal  unless  the  examiner  be  atten- 
tive to  the  play  of  tendons  when  the  tests  are  made.  The  spastic  con- 
dition is  also  followed  by  contractures  which  place  the  limbs  in  the  posi- 
tions so  characteristic  of  hemiplegia  in  adults.  Here  also  are  similar 
attitudes  and  gaits. 

Sensory  disturbance  is  apparently  absent  even  in  the  recent  cases,  and 
electrical  reaction  modifications  are  never  present.  The  trophic  condition 
of  the  paralytic  limbs,  however,  is  reduced,  as  is  shown  in  the  unequal 
growth  on  the  two  sides  as  time  goes  on.  This  results  in  some  deformity. 
The  shoulder  girdle  is  smaller  on  the  affected  side,  the  chest  and  arm 
less  in  size,  and  the  pelvis  and  lower  extremity  unequal  to  corresponding 
parts  of  the  sound  side.  The  half  of  the  head  and  face  on  the  paralytic 
side  may  be  of  inferior  dimensions.  The  limping  gait  of  hemiplegia  is 
increased  by  the  shortened  limb,  the  pelvis  tilts,  the  spine  becomes 
scoliotic,  and  the  retarded,  paralytic,  contractured  upper  member  is  held 
to  the  side  of  the  body  and  usually  flexed  in  all  its  joints. 

From  nine  months  to  two  years  after  the  paralytic  onset  the  para- 
lyzed side,  especially  the  hand,  in  over  one-half  of  the  cases,  is  animated 
by  automatic  and  involuntary  choreoid  or  athetoid  movements,  which  often 
attain  a  wonderful  complexity  and  range.  They  may  also  involve  the 
face,  but  seldom  to  the  degree  that  is  observed  in  diplegic  cases.  These 
athetoid  movements  are  usually  intensified  upon  voluntary  effort  to  use  the 
limb.  Attempts  to  grasp  an  object  will  often  cause  the  fingers  to  move 
widely  apart  in  extreme  extension,  and  after  clumsy,  slow  movements 
the  object  is  awkwardly  and  insecurely  held  or  the  attempt  fails.  In 
some  cases  the  extremities,  particularly  the  upper  one,  are  writhed  about 
in  the  most  vigorous,  serpentine,  and  purposeless  way,  striking  the 
patient's  face  or  getting  into  awkward  positions  behind  the  neck  or  back. 
The  athetosis  in  rare  cases  is  persistent  day  and  night,  in  others  it 
subsides  during  sleep,  and  in  still  others,  and  perhaps  the  majority  of 


244 


DISEASES   OF  THE  BRAIN  PROPER. 


cases,  it  only  appears  when  provoked  by  voluntary  effort  or  emotional 
disturbance.      In    the    cases    that   are    marked    by    excessive    athetoid 


Fig.  90. — Attitude  and  deformity 
in  cerebral  right  hemiplegia  in  a  boy 
of  seven. 


Fig.  91. — Right  hemiplegia  dating 
from  birth,  with  overaction  in  right  side 
of  face  and  athetosis  of  right  hand. 


motility  the  muscles,  from  constant  though  involuntary  use,  are  fre- 
quently firm  and  well  nourished.  They  may  even  be  overdeveloped. 
Clark  1  has  proven  hypertrophy  in  such  cases  and  actual  enlargement 
of  bones  has  been  shown  by  the  X-ray.  On  the  other  hand,  well- 
marked  atrophy  may  be  encountered.  The  joints  frequently  present  a 
marked  increase  in  their  range  of  motion  so  that  the  digits,  for  instance, 
can  nearly  be  laid  on  the  dorsal  aspect  of  the  hand.  This  condition  is 
particularly  marked  in  the  severe  cases,  beginning  very  early  in  life. 
The  ameboid  and  tentacle-like  movement  of  the  fingers  and  toes  in 
athetosis,  once  recognized,  can  hardly  be  mistaken  for  anything  else. 
Associated  movements  by  which  the  paralytic  member  apes  the  positions 
and  motions  of  the  sound  fellow  reach  their  highest  development  in 
these  cases  in  children. 

In  the  hemiplegic  cases  the  arm  usually  recovers  less  than  the  leg 
or  face  and  the  athetoid  condition  is  commonly  confined  to  it.  Con- 
tractures predominate  in  the  foot  and  leg,  producing  an  equinovarus, 
rarely  a  valgus,  deformity,  which  is  also  favored  by  the  shortness  of  the 
limb^  and  there  is  some  tendency  to  contractured  flexion  at  the  knee  and 
hip.  The  toes  are  frequently  cramped  and  distorted  by  the  contract- 
ures and  hammer-toe  is  a  usual  deformity,  but  when  athetosis  is  present 
1  "Jour.  Kerv.  and  Ment.  Dis.,"  Nov.,  1902. 


THE  CEREBRAL  PALSIES  OF  CHILDREN. 


245 


an  abnormal  range  of  passive  and  active  motion  is  found.  In  the  face 
the  tendency  to  contracture  is  frequently  only  shown  in  an  overaction 
of  the  facial  muscles  during  emotional  expressions,  as  shown  in  figure 
91,  the  boy  being  pleased  at  having  his  picture  taken.  Any  degree  of 
mental  enfeeblcment  may  be  present  in  hemiplegic  cases,  but  usually  it 
is  much  less  marked  than  in  the  bilateral  form  and  may  be  practically 


Fig.  92.  —  Diplegia  dating 
from  birtb.  Rigidities  and  spas- 
tic attitude  witii  cross-legged 
gait. 


Fig.  93.— Di| 


Icgir  ciiiigenital  palsy  with  athetosis 
in  face  and  all  extremities. 


absent.     The  tendency  to  epileptic  attacks  and  mental  deterioration  is 
pronounced  in  the  hemiplegic  form,  and  will  be  mentioned  again. 

Diplegic  Cases. — In  the  bilateral  form  the  unilateral  conditions 
of  the  hemiplegic  cases  are  present  on  both  sides,  but  the  lower  limbs 
are,  as  a  rule,  more  strongly  affected  than  the  upper  and  the  face  may 
show  little  or  no  motor  impairment.  In  rare  cases  the  trouble  seems 
to  be  limited  to  the  lower  limbs,  and  these  instances  are  sometimes 
described  as  paraplegic.  Almost  invariably,  however,  the  presence 
of  speech  difficulties,  of  mental  defect,  and  of  clumsiness  in  the  use  of 
the  hands  will  betray  the  diplegia.  The  frequency  of  spinal  hemor- 
rhages in  stillborn  children,  as  determined  by  Spencer,  for  instance, 
gives  ground  to  suppose  that  in  very  exceptional  instances  the  cord- 
lesion  may  alone  occur  and  a  true  paraplegia  result  if  the  child 
survive.  These  bilateral  cases  are  mainly  of  prenatal  and  birth  origin, 
only  a  small  number  arising  after  the  first  few  months  of  infancy  and 
practically  none  after  the  third  year  of  life.  The  more  extensive 
injury  to  the  brain  is  attended  almost  of  necessity  by  greater  mental 
impairment  and  idiocy  marks  many  cases.  Microcephalia  some- 
times results  or  the  skull  may  have  so  defective  a  shape  that  poren- 


246  DISEASES  OF  THE  BRAIN  PROPER. 

cephalia  and  anencephalia  may  be  suspected.  Such  children  are 
either  noticed  to  be  rigid  and  inactive  at  birth,  or  after  birth-in- 
juries and  convulsive  manifestation  develop  rigidity  and  contractures 
during  the  early  months  of  infancy.  Frequently  it  is  only  when 
the  child  is  found  incapable  of  learning  to  sit  up  or  to  use  its  legs  in 
efforts  at  walking  that  the  paralytic  state  is  recognized.  Mental  back- 
wardness, slowness  in  the  development  of  speech,  and  other  indications 
of  injury  to  the  highest  brain  functions  are  often  neglected  until  the 
third  or  fourth  year  in  the  misguided  hopefulness  that  the  child  will 
"  outgrow  it."  The  rigichty  and  spastic  state  is  frequently  so  great  that 
the  legs  and  arms  present  a  "  lead  pipe "  resistance  to  passive  move- 


Fig.  94.— Athetosis  of  feet. 

ments.  A^oluntary  efforts  are  hindered  or  defeated,  and  some  of  these 
■children  never  get  the  hands  to  the  face,  much  less  their  toes  to  their 
mouths.  They  are  difficult  to  handle  and  to  dress.  Their  arms  and 
legs  are  as  unmanageable  as  stiff-jointed  manikins.  They  are  "  all 
thumbs"  and  awkwardness.  The  spasticity  in  the  lower  extremities, 
which  tends  to  flex  hips  and  knees  and  especially  to  adduct  the 
thighs,  holds  the  knees  closely  together,  makes  it  difficult  to  dress 
and  bathe  them  as  infants  and  defeats  locomotion  later  on.  Placed 
on  a  chair,  the  lower  limbs  have  a  tendency  to  maintain  a  rigid 
horizontal  position.  If  they  are  placed  on  their  feet  the  legs  cross, 
the  heels  can  not  be  brought  to  the  floor,  and  if  steps  are  taken  it 
is  only  by  advancing  the  foot  that  is  in  front  and  then  bringing  up  the 
one  in  the  rear.  As  they  grow  older  a  tendency  to  equinovalgus  or 
varus  and  genu  valgum  is  induced,  but  by  keeping  the  feet  widely 
separated  they  are  able  to  dodge  one  knee  around  the  other.  They  thus 
advance  in  a  shuffling,  knee-rubbing,  toe-scraping,  laborious  manner,  to 
which  the  increased  reflexes  and  ankle-clonus  give  a  jerky,  tremulous, 
spastic  character. 

In  some  cases  more  or  less  athetosis  is  present  in  all  four  members, 
and  occasionally  it  invades  the  face  and  even  the  tongue,  pharynx,  and 
larynx.  When  the  athetosis  is  general,  and  particularly  when  it  in- 
volves the  feet,  the  patients  are  rendered  almost  completely  helpless 
physically. 

Little's  Disease. — English,    German,   and   American   writers   are 


THE  CEREBRAL  PALSIES  OF  CHILDREN.  247 

prone  to  use  the  terra  Little's  disease  in  a  generic  sense  to  embrace  all 
cerebral  palsies  in  childhood.  French  writers,  of  the  Salpetriere  school 
especially,  insist  upon  a  clinical  form  of  spastic  diplegia  to  which  they 
give  the  distinctive  name  of  Little's  disease,  after  the  London  surgeon 
who  among  the  first  called  specific  attention  to  this  class  of  disorders. 
As  these  cases  referred  to  present  certain  definite  characters  and  a  more 
hopeful  future  than  the  others,  they  merit  separate  mention. 

The  initial  condition  is  a  premature  birth  or  the  birth  at  term  of  a 
markedly  undeveloped  child.  This  means  a  defective  pyramidal  tract 
in  the  spinal  cord  and  brain.  Such  children  usually  weigh  less  than 
four  pounds.  Spasticity  results  in  the  territory  of  the  lower  neuron 
from  the  lack  of  control  due  to  the  undeveloped  condition  of  the  upper 
neuron.  These  children  are  rigid  from  birth,  but  the  mental  qualities 
are  not  necessarily  diminished,  and  if  they  survive,  the  tendency  is  to 
continuous  improvement  as  the  pyramidal  tracts  develop.  This  develop- 
ment is  never  complete,  but  continues  up  to  the  age  of  full  growth. 
The  motor  condition  is  one  of  pure  spasticity 
and  there  is  no  tendency  to  athetoid  move- 
ments or  epileptic  attacks.  The  gait  remains 
more  or  less  spastic  through  life,  which  may 
be  a  long  one  marked  by  ordinary  or  even  bril- 
liant mental  activity. 

Amaurotic  Family  Idiocy. — Sachs  ^  pro- 
poses this  clinical  designation  for  a  group  of 
cases  of  which  he  collected  nineteen  occurring 
in  ten  families,  with  three  autopsies.  Numer- 
ous other  observations  have  since  appeared  in 
current  literature,  notably  those  reported  by 
Collier. 2  These  children  are  born  at  term 
and  present  healthy  physical  and  mental  de- 
velopment up  to  the  age  of  four  to  ten  months, 
when  they  become  weak,  lethargic,  and  stupid. 
Ocular  symptoms  soon  appear  and  blindness 
due  to  optic  atrophy  develops.  Frey  ^  does  not 
agree  with  Sachs  that  the  condition  is  merely 
agenetic,  but  considers  the  changes  found  to  be 
postpartum,  presenting  for  childhood  the  state  Fig.  95.— Case  of  Little's 

.,  ,i'1j         1  1  •■  disease.      Rigidities  and  cioss- 

recognized  as  amvotropnic  lateral  sclerosis  in  leg  from  spasticity  in  a  child 
adults.  The  ophthalmoscopic  picture  is  said  to  be  ^''^'''"'^ '''''' '""''"''  ^'  ^"■''^• 
very  characteristic.  Beard^  states  that  the  appear- 
ance is  not  that  of  pronounced  atrophy.  The  disc  is  not  markedly  blanched, 
but  the  fovea  centralis  presents  a  clear-cut  liver-colored  plaque  surrounded 
by  a  halo  of  grayish-white  which  does  not  obscure  the  retinal  vessels.  Nys- 
tagmus, ocular  deviations,  and  pupillary  findings  have  shown  convolutional 
simplicity  and  cortical  cellular  degeneration.    Sachs  ^  reports  degenerative 

1  ' '  New  York  Medical  Journal, ' '  May  30,  1896.  2  '  *  Brain, ' '  1899. 

3  "Deut.  Arch.  f.  klin.  Med.,"  Bd.  Ixviii. 

4  "Jour.  Nerv.  and  Ment.  Dis.,"  May,  1900. 
*  "Jour.  Nerv.  and  Ment.  Dis.,"  Jan.,  1903. 


mi 


248  DISEASES  OF  THE  BRAIN  PROPER. 

changes  in  the  gray  matter  of  the  entire  cerebrospinal  axis  and  even  in  the 
root  ganglia.  These  changes  have  been  attributed  to  toxic  processes,  but 
none  of  the  alleged  toxic  factors  can  be  accepted  as  competent  in  all  in- 
stances. As  many  as  four  cases  have  been  observed  in  a  single  family, 
and  the  inherent  anatomical  lack  in  the  brain  is  not  explained  by  inherited 
.syphilis,  which  may,  however,  produce  a  very  similar  clinical  picture. 

Epileptic  Attacks. — One  of  the  most  serious  features  of  the  cere- 
bral palsies  of  children  is  the  marked  tendency  to  the  development  of 
epikptk-  attacks.  These  appear  in  fully  one-half  of  all  cases.  They  are 
due  to  the  brain-lesion,  and  usually  are  most  marked  in  the  paralytic 
limbs,  but  with  a  tendency  to  spread  and  become  generalized.  True 
Jacksonian  fits  are  Ijut  rarely  encountered.  In  some  cases  the  initial 
eclamptic  attack  is  at  once  followed  at  regular  intervals  of  weeks  or 
months  by  these  seizures.  In  others  they  do  not  appear  for  a  period  of 
years  and  may  be  preceded  by  petit  mal  attacks.  They  are  always  to  be 
expected,  and  when  established  constitute  a  serious  menace  to  the  health 
and  mental  state  of  the  patient.  The  ordinary  tendency  of  epilepsy  to 
induce  dementia  is  exaggerated  in  these  already  defective  brains. 

Diagnosis. — The  diagnosis  of  cerebral  palsy  when  the  condition  is 
well  marked  should  present  no  difficulty.  In  the  slighter  grades  the 
epileptic  attacks  or  the  choreoid  movements  are  frequently  mistaken  and 
the  organic  basis  overlooked.  The  combination  of  head  symptoms  and 
mental  enfeeblement  with  the  motor  difficulties  in  diplegic  cases  should 
be  sufficiently  striking.  The  hemiplegic  distribution  of  paralysis  can 
tell  but  one  story.  In  cases  presenting  paraplegic  features  it  may 
require  a  careful  investigation  to  locate  the  trouble  in  the  brain.  The 
history  here,  as  elsewhere,  is  a  valuable  guide.  In  addition  the  pre- 
served electrical  reactions,  the  comparatively  normal  trophic  conditions, 
and  the  exaggerated  reflexes  should  readily  exclude  a  cord-lesion.  The 
teratological  defect  which  furnishes  the  cases  of  amaurotic  family  idiocy 
and  the  defective  development  of  Little's  disease  must  both  be  deci- 
phered from  the  clinical  data  or  the  post-mortem  findings. 

Prognosis. — The  prospects  in  these  diverse  cases  vary  widely,  but 
it  may  be  positively  stated  that  complete  recovery  never  occurs  and  that 
a  perfectly  normal  condition  is  never  attained.  In  the  cases  of  prenatal 
origin  the  prognosis  must  rest  on  the  observed  course  of  development 
during  the  first  year  of  life.  Improvement  in  motor  control  and  the 
appearance  of  mental  awakening  are  hopeful  indications,  but  the  major- 
ity of  these  cases  are  doomed  to  mental  retardation  or  idiocy  and  more 
or  less  physical  helplessness.  The  cases  that  conform  to  the  type  of 
Little's  disease  are  exceptions.  In  these  the  prognosis  for  mental  de- 
velopment is  good  and  progressive  motor  improvement,  up  to  a  certain 
point,  may  be  confidently  expected.  Amaurotic  family  idiocy,  which  is 
a  congenital  defect,  is,  at  present,  of  absolutely  fatal  prognosis. 

In  the  cases  of  birth  palsy  the  intensity  of  the  convulsions,  their 
persistence,  and  the  apparent  extent  of  brain  injury,  in  a  very  rough 
way,  guide  the  prognosis  as  to  life.  If,  after  a  few  months,  spasticity 
is  still  absent  and  some  voluntary  motion  occurs  in  the  paralyzed  limbs, 
the  prospects  are  much  improved.      The  question. of  mental  development 


THE  CEREBRAL  PALSIES  OF  CHILDREN.  249 

can  only  be  decided  by  watching  the  course  of  events.  In  the  acquired 
cases  the  prognosis  is  much  the  same  as  in  the  apoplexies  of  adults  as 
far  as  motility  is  concerned.  The  return  of  motion  in  the  paralytic  limb 
and  the  absence  of  contractures  permit  hope  of  a  fair  degree  of  motor 
restoration.  Speech  is  usually  restored,  unless  the  frontal  lobes  have 
been  injured  and  mentality  impaired.  The  loss  of  sight  and  more 
especially  of  hearing  is  likely  to  prevent  mental  development  and  to  in- 
duce idiocy.  Whenever  epileptoid  attacks  appear,  they  constitute  a  very 
serious  feature  and  foreshadow  dementia.  They  are  somewhat  moi-e 
common  in  the  late  than  in  the  congenital  cases  and  in  the  hemiplegic 
than  in  the  diplegic  palsies. 

Treatment. — In  the  birth-palsy  cases  the  nutrition  of  the  child  is 
the  first  problem,  as  suckling  and  swallowing  are  often  impossible.  The 
evidence  of  meningeal  hemorrhage  is  usually  so  indefinite  that  trephin- 
ing, which  has  been  proposed,  can  rarely,  if  ever,  be  practised.  The 
convulsions  must  be  subdued  by  cold  applications  to  the  neck  and  head, 
and  by  sedatives,  such  as  chloral,  bromid,  morphin,  and  by  continued 
chloroformization,  if  necessary.  The  bowels  should  be  thoroughly 
opened,  preferably  by  means  of  calomel.  The  same  measures  are  indi- 
cated as  in  older  cases  of  acute  hemiplegic  convulsions  and  in  convul- 
sions generally. 

In  the  later  cases  the  management  of  the  apoplectic  and  paralytic  states 
is  the  same  as  for  adults  (see  p.  212).  From  the  first,  the  nutrition 
of  the  paralytic  muscles  and  the  tendency  to  contractures  must  be  met 
by  massage,  passive  movements,  and  faradism.  As  soon  as  contractures 
appear,  the  massage  and  electricity  must  be  used  only  on  the  weaker 
muscles — that  is,  as  a  rule,  only  on  the  extensors.  The  use  of  these 
measures  to  increase  the  strength  of  the  overacting  muscles  may  occa- 
sion decided  harm.  Unfavorable  positions  of  the  limbs  must  be  obviated 
by  mechanical  measures,  if  necessary.  Such  means  may  do  much  to 
retard  contracture,  to  hasten  and  increase  voluntary  control,  and  to 
favor  growth  in  the  paralytic  members.  Orthopedic  appliances  and 
tenotomies  in  neglected  cases  sometimes  secure  much  permanent  improve- 
ment. Transplantation  of  tendons  has  lately  come  into  prominence,  and 
in  some  instances  can  be  resorted  to  with  fair  prospects  of  improvement. 

Athetosis  may  be  subdued  to  a  considerable  extent  by  fixation 
appliances  or  plaster-of-Paris  splints.  Hammond  reported  some  cases 
temporarily  much  benefited  by  nerve-stretching,  and  Horsley  has  extin- 
guished the  athetosis  by  excising  the  corresponding  brain-centers.  In 
one  such  case  the  writer  advised  the  removal  of  the  cortical  centers  for 
a  very  unruly  upper  extremity,  and  the  resulting  palsy  in  the  member 
was  replaced  finally  by  slight  but  useful  voluntary  control. 

When  idiocy  is  present  it  is  open  to  educational  methods  only.  The 
epilepsy  that  so  frequently  complicates  these  cases  can  be  controlled  to 
some  extent  by  bromids  or  combinations  of  various  sedatives  with 
bromids.  When  the  attacks  are  of  a  distinctly  Jacksonian  character, 
the  question  of  operation  will  come  forward.  Every  case  must  be  con- 
sidered by  itself.  As  in  many  instances  the  condition  is  one  of  cerebral 
sclerosis,  no  operation  can  do  good.     If  there  be  a  cystic  state,  explora- 


250  DISEASES  OF  THE  BRAIN  PROPER. 

tion  and  evacuation  may  be  productive  of  much  relief.  In  some  cases 
the  mere  effect  of  the  operation  has  been  temporarily  beneficial;  in  others 
it  has  acted  by  relieving  pressure.  Removal  of  cortical  centers  in  Jack- 
sonian  fits  of  this  class  is  very  likely  to  merely  displace  the  initial  symp- 
toms and  to  add  to  the  traumatic  conditions  already  present.  Linear 
craniotomy  when  the  brain  is  diseased  can  only  be  condemned.  If  it 
have  any  place  it  is  in  the  cases  that  present  closed  fontanels  at  birth 
with  microcephalic  heads,  the  possible  result  of  early  synostosis. 


CHAPTER   XI. 
TUMORS  OF  THE  BRAIN. 

The  encephalon  is  frequently  invaded  by  various  new  growths 
common  to  other  parts  of  the  body,  and  by  a  number  of  neoplasms  that 
are  practically  found  only  within  the  sknll.  In  addition,  new  forma- 
tions arising  from  the  meninges  and  cranial  walls,  while  not  strictly 
brain-tumors,  present  symptoms  that  are  identical  with  lesions  of  the 
cortex,  and  are  localized  in  the  same  way.  The  term  "  brain-tumor  "  is 
here  taken  broadly  to  cover  new  formations  within  the  skull.    . 

Etiology. — The  causation  of  brain-tumors  is  an  obscure  subject. 
Many  of  them  arise  by  metastasis  from  distant  morbid  fields,  as  is 
usually,  if  not  always,  the  case  in  tubercular  growths,  carcinomata,  and 
parasitic  cysts  and  masses.  Some  arise  by  intracranial  extension  from 
the  orbit,  pharynx,  and  cranial  bones.  Heredity,  aside  from  tubercular 
cases,  plays  a  very  insignificant  if  not  an  entirely  negative  role. 
Traumatism  has  probably  been  too  frequently  assigned  as  the  inciting 
cause  of  brain-tumor,  but  it  undoubtedly  is  competent  in  some  instances. 
Thus,  continuous  symptoms  have  arisen  within  a  few  days  of  a  head 
injury,  and  a  tumor  has  subsequently  been  found  at  the  traumatic  site  or 
in  the  brain  beneath.  There  can  be  no  doubt  that  even  slight  head 
injuries  may  localize  tubercular  and  syphilitic  activity  and  lead  to  cor- 
responding tumor  growth.  Sarcoma  and  glioma  are  the  neoplasms  that 
seem  to  be  most  frequently  attributed  to  trauma,  but  at  the  same  time 
they  are  among  the  most  common  of  brain-tumors. 

No  age  is  exempt  from  tumor  growth  within  the  cranium.  The 
great  majority  of  cases  occur  in  childhood  and  active  adult  life.  The 
activity  of  tuberculosis  in  childhood,  and  the  prevalence  of  syphilis  in 
young  adults,  as  well  as  liability  to  traumatic  influences,  may  in  part 
account  for  this.  Males  are  somewhat  more  subject  to  cerebral  tumor 
than  females. 

Pathological  Anatomy. — Of  all  brain-tumors  tubercle  furnishes 
the  largest  proportion.  The  implantation  of  the  tubercular  process 
within  the  brain  sometimes  gives  rise  to  the  formation  of  large,  solitary, 
isolated,  often  encysted  caseous  masses  that  may  be  single,  but  are 
multiple  in  about  one-half  of  the  cases.  Tubercular  tumors  favor  the 
base  and  the  course  of  the  large  cerebral  and  cerebellar  vessels,  which 
recalls  the  usual  propagation  of  tubercular  meningitis.  No  part  of  the 
brain,  however,  is  exempt.    They  do  not  destructively  invade  the  brain- 


TUMORS  OF  THE  BRAIN. 


251 


tissue,  but  displace  it  and  act  as  foreign  bodies,  causing  pressure 
atrophv.  About  them  may  often  be  found  an  area  of  tubercular  infil- 
tration and  inflammatory  activity,  especially  if  they  are  seated  so  as  to 
involve  the  meniuges.  Three-fourths  of  the  cases  occur  before  the  age 
of  twenty.  The  tumors  vary  in  size  from  a  pea  to  a  lien's  egg,  or  even 
a  larger  size,  and  in  number  from  one  to  a  score. 

Sarcomatous  growths  are  next  in  frequency.  Usually  they  present 
the  distinctive  and  important  character  of  being  more  or  less  encapsu- 
lated and  sharply  separated  from  the  brain-tissue,  from  which  they  can, 
theretbre,  if  accessible,  be  easily  enucleated.  As  a  rule,  they  are  out- 
growths of  the  cranial  dura  or  periosteum,  and  the  majority  of  them  are 
situated  in  the  basilar  region,  involving  the  brain-axis.  In  compara- 
tively rare  instances  they  infiltrate  the  brain-tissue,  or,  arising  at  the 
vertex,  spread  out  broadly.  They  are  of  rapid  growth,  and  in  a  given 
case  furnish  pronounced,  persistent,  and  uniform  symptoms.  They 
present  the  variations  of  cellular  elements  that  mark  sarcomata  else- 
where.    As  a  rule,  they  are  single. 

Glioma  is  peculiar  to  nervous  structures.  It  arises  from  the  neu- 
roglia and  finds  its  most  usual  seat  in  the  brain,  though  it  may  occur  in 


Fig.  96.- 


*arcoma  of  right  temporosphenoidal  lobe.    A,  Basilar  surface ;  B,  transverse  section 
(Dr.  W.  A.  Jones). 


the  spinal  cord  or  retina.  It  presents  a  reddish,  vascular  color  and  a 
soft  consistency  quite  like  that  of  the  brain-substance.  Glioma  is  emi- 
nently an  infiltrating  and  a  destructive  growth.  Its  outlines  are  difficult 
to  determine.  Owing  to  its  strangulating  effect,  the  center  of  a  glioma  is 
frequently  filled  with  softened  detritus  and  fatty-degeneration  products, 
which  may  become  fluid  and  the  growth  thereby  cystic.  Many  alleged 
local  '^  brain-hypertrophies "  have  been  gliomatous  infiltration  in  fact, 
and  the  microscopic  examination  of  "cyst-walls"  has  alone  discovered 
the  true  nature  of  the  lesion  in  other  instances.  The  favorite  location 
of  glioma  is  the  white  substance  near  the  cortex,  and  it  may  infiltrate 
large  areas,  even  the  greater  part  of  a  hemisphere.  Ordinarily  it  is  single. 
In  consistencv  thev  are  soft,  often  hiffhlv  vascular,  and  mav  in  some 


252 


DISEASES  OF  THE  BRAIN  PBOPER. 


cases  be  easily  mistaken  for  angiomata.  Hemorrhages  not  infrequently 
occur  in  them.  In  other  cases  a  great  amount  of  interstitial  fluid  gives 
them  a  myxoid  character. 


Fig.  97. — Glioma  of  cerebellum  containing  recent  and  old  hemorrhages. 


Fig.  98. — Gliomata  of  right  temporosphenoidal  lobe  and  left  parietal  lobe. 


Carcinomata,  practically  speaking,  are  found  in  the  brain  only  as 
metastatic  growths  arising  from  primary  cancer  in  the  body  organs, 
breast,  etc.,  or  through  direct  invasion  by  extension  from  orbital-  or  otlier 
cranial   and  facial  carcinomatous   growths.      They  are  also  practically 


TUMORS  OF  THE  BRAIN.  253 

confined  to  the  second  half  of  life.  Uncontrolled  by  the  soft  tissne  of 
the  encephalon,  earcinomata  rapidly  invade  the  brain,  forming  ill- 
defined,  nodular,  rarely  encapsulated,  very  vascular,  and  practically  in- 
operable tumors.  When  arising  secondarily  from  cancer  in  the  body 
organs,  especially  those  in  the  thorax,  carcinoma  of  the  brain  locates 
by  preference  in  the  neighborhood  of  the  great  vessels  of  the  base.  In 
other  instances  it  springs  from  the  choroid  structures  and  the  epithelial 
lining  of  the  ventricles,  or  from  the  dura  and  pia  mater. 

Cysts  form  tumors  in  the  brain  with  comparative  frequency.  An 
encysted  hemorrhage  or  softened  infarct  does  not  ordinarily  give  rise  to 
progressive  or  marked  irritative  symptoms,  and  need  not  be  here  con- 
sidered. An  encysted  and  latent  abscess  may,  however,  produce  all  the 
symptoms  of  a  brain-tumor,  which  in  fact  it  is.  Cysts  arising  from 
parasites,  such  as  the  cysticercus  and  echinococcus,  are  rather  common 
in  some  parts  of  the  world,  but  are  distinctly  rare  in  the  United  States. 
Diamond  1  could  only  find  eight  reported  cases  of  cerebral  cysticercus  in 
American  literature.  The  central  breaking  down  of  sarcomata,  and  espe- 
cially of  gliomata,  produces  cysts  the  nature  of  which  may  be  indetermin- 
ate without  histological  search.  Rarer  forms  are  due  to  ependymal  inclu- 
sions in  embryonic  development,  producing  ventricular  cysts  or  cysts  in 
the  posterior  portion  of  the  pituitary  body  later  in  life.  Dermoid 
cysts  have  also  been  encountered  within  and  outside  the  dura,  and 
especially  in  the  cerebellum.  Cyst  development  is  usually  slow,  and 
the  resulting  tumor  acts  as  a  displacing  foreign  body.  Their  diagnosis 
is  important,  as  they  are  readily  evacuated  and  the  cyst-wall  may  be 
removed  when  situated  in  a  surgically  approachable  part  of  the  brain. 
Syphilitic  tumors  of  a  gummatous  sort  in  the  brain  are  more  fre- 
quent than  statistics  would  indicate.  Owing  to  their  partial  amenability 
to  treatment  and  their  readily  accepted  consequences  they  are  seldom 
reported.  As  a  rule,  they  spring  from  the  meninges  and  large  vessels, 
and,  when  deeply  seated,  are  usually  the  ingrowth  from  one  of  the 
penetrating  folds  or  vessels.  They  may  be  definitely  limited  or  sur- 
rounded by  softened  brain-tissue,  and  have  no  tendency  to  infiltrate. 
Their  usual  location  is  in  the  hemispheres,  especially  at  the  base,  or  in 
the  pons.  They  rarely  occur  in  the  cerebellum  or  central  ganglia. 
After  treatment  their  early  soft,  caseous,  and  gelatinous  character 
may  be  changed  to  a  shrunken,  degenerated,  and  fibrous  condition. 
They  are  usually  multiple,  nodular  in  form,  and  about  the  size  of  a 
chestnut.  They  occur  as  the  result  of  acquired  syphilis,  and  conse- 
quently usually  in  adults  at  periods  varying  from  a  few  months  to  many 
years  after  the  primary  lesion.  They  are  commonly  attended  by  other 
syphilitic  disturbances  of  the  brain,  such  as  endarteritis,  meningitis,  and 
cranial-nerve  lesions.  Of  rapid  growth,  they  usually  promptly  recede 
to  some  degree  under  adequate  treatment,  but  their  absolute  removal 
by  medication  is  always  questionable. 

Many  other  tumor  forms  are  occasionally  found  in  the  brain. 
Cerehroma  is  an  embryological  infolding  of  the  gray  mantle,  which 
becomes  occluded,  usually  in  the  white  substance,  and,  later,  takes  on 
1  "Jour.  Am.  Med.  Assoc,"  June,  1899 


254  DISEASES  OF  THE  BRAIN  PROPER. 

active  proliferation,  forming  a  heterotopic  tumor.  Fibroma,  angioma, 
neuroma,  psammoma,  papilloma  of  the  choroid  plexus  and  Pacchionian 
bodies,  adinomycosis,  lipoma,  teratoma,  osteoma,  cholesteatoma,  etc., 
merely  require  mention.  The  pituitary  tumor  associated  with  acromegaly 
is  discussed  under  that  liead,  but  tumors  of  various  sorts,  such  as  adenoma 
and  adenosarcoma,  occur  at  this  point  without  such  association. 

Aneurysms  sometimes  give  rise  to  symptoms  of  intracranial  tumor. 
Thev  arise,  especially  after  middle  life,  as  the  result  of  arterial  disease, 
discussed  in  chapter  v,  or  they  may  be  due  to  traumatism.  Aneurysms 
of  a  cirsoid  character  and  of  great  extent  that  produce  brain  symp- 
toms are  occasionally  encountered  on  the  meningeal  arteries.  The 
cerebral  vessels  present  aneury^sms  usually  of  a  globular  or  pyriform 
shape.  Their  favorite  location  is  at  the  base  and  in  the  Sylvian  fissures, 
at  the  bend  of  the  carotids  and  in  the  basilar  artery,  but  they  occa- 
sionally develop  on  the  perforating  arteries  and  may  attain  considerable 


Fig.  99. — Aneurysm  of  the  basilar  artery. 

size.  The  formation  of  miliary  aneurysms  and  their  relation  to  cerebral 
hemorrhage  have  already  been  indicated.  Occasionally  a  patient  ^vith 
cerebral  aneurysm  is  conscious  of  its  pulsations  and  hears  the  bruit. 
The  bruit  may  also  sometimes  be  heard  by  auscultation  of  the  cranium, 
but  vascular  murmurs  have  also  been  heard  in  a  case  of  extensive  soften- 
ing. The  chief  symptoms  of  aneurysm  are  due  to  pressure  upon  the 
ci'anial  nerves  and  brain-centers. 

All  brain-tumors  cause  more  or  less  circumferential  destruction 
of  brain-tissue.  This  is  at  a  minimum  in  slow-growing  tubercles 
and  reaches  its  maximum  in  rapidly  growing  and  infiltrating  glioma. 
Almost  invariably,  if  the  meninges  are  reached,  an  inflammatory 
thickening  over  the  growth  is  added.  In  the  case  of  tubercle  and 
syphilis  a  more  or  less  diffuse  meningitis  is  commonly  present,  sooner 
or  later.  The  interpolation  of  a  new  growth  within  the  resist- 
ing walls  of  the  skull  means   increased    intracranial   pressure  and  dis- 


TUMORS  OF  'THE  BRAIN.  255 

turbed  vascular  conditions.  The  effects  are  serious,  relative  to  the 
intensity  of  the  pressure,  the  rapidity  with  which  it  is  established,  and 
the  location  of  the  growth.  Even  a  small  tumor  in  the  circumscribed 
space  under  the  tentorium  produces  pressure  rapidly.  In  the  same 
way,  if  located  near  the  falx  or  other  resisting  structure,  its  pressure 
effects  seem  to  be  greater.  On  the  other  hand,  if  of  slow  growth  and 
of  a  non-destructive  character,  a  tumor  may  displace  large  portions  of 
a  hemisphere,  especially  in  the  latent  regions  of  the  right  side,  and 
attain  enormous  proportions,  without  producing  notable  symptoms. 
This  pressure  is  felt  not  only  in  the  vicinity  of  the  tumor,  but  through- 
out the  encephalon,  and  may  cause  symptoms  and  even  inflammatory 
disturbance  at  a  distance.  Tumors  so  located  as  to  obstruct  the  return 
circulation  from  the  ventricles  by  occluding  the  straight  sinus  and  the 
veins  of  Galen  produce  a  dropsical  condition  of  these  cavities,  an 
internal  hydrocephalus,  with  extreme  pressure  indications.  Even  the 
bony  walls  of  the  cranium  over  the  tumor  are  thinned  and  eroded  in 
some  instances,  and  that,  too,  when  the  tumor  is  not  superficial. 

A  number  of  observers  have  noted  changes  in  the  spinal  cord  in  brain- 
tumor  cases.  These  seem  mainly  to  affect  the  posterior  portions  of  the 
cord  and  the  posterior  roots.  Ursinii  considers  them  of  toxic  character, 
and  Lubarsch  has  found  somewhat  similar  changes  in  a  case  of  gastric 
cancer.  The  analogous  changes  in  anemias  and  cachexias  are  significant 
in  this  connection.  Kirschgiisser,^  however,  believes  the  cord  changes 
to  be  secondary  to  increased  tension  in  the  dural  sheath.  Batten  and 
Collier  ^  take  a  similar  view,  and  find  such  changes  in  over  half  of  all 
cases.  Certain  cases  in  which  the  tumor  disintegrates  the  motor  tract 
within  the  skull  show  degenerative  changes  in  the  direct  and  crossed 
pyramidal  tracts  in  the  cord. 

Symptoms. — The  symptomatology  of  brain-tumors  presents  the 
widest  variations.  The  clinical  picture  is  dependent  upon  the  situa- 
tion of  the  growth  and  modified  in  its  evolution  by  the  nature  of  the 
tumor.  A  slow-growing  mass  starting  from  the  meninges  may  deform 
an  entire  hemisphere  without  giving  rise  to  symptoms,  while  another  of 
insignificant  volume  may  produce  the  most  marked  motor,  sensory,  and 
mental  disturbances,  or  lead  to  sudden  death.  We  may  divide  the  symp- 
toms of  brain-tumor  into  :  (1)  Those  which  are  presented  irrespective 
of  the  nature  and  location  of  the  growth, — general  symptoms  ;  (2)  those 
dependent  upon  the  situation  of  the  neoplasm, — -focal  symptoiiiis ;  and 
(3)  topical  symptoms,  those  at  the  superficial  site.  Under  certain  condi- 
tions the  general  symptoms  have  some  localizing  value,  as  will  be  pointed 
out  seriatim. 

General  symptoms  of  intracranial  growths  are:  (1)  Headache; 
(2)  generalized  convulsions ;  (3)  mental  impairment ;  (4)  double  optic 
neuritis  and  optic  atrophy ;  (5)  vomiting,  and  (6)  vertigo.  Tempera- 
ture changes  above  and  below  the  normal,  alterations  in  respiration  and 
pulse  rhythm,  polyuria,  glycosuria,  insomnia,  delirium,  stupor,  coma, 
slow  speech,  and  malnutrition  are  common  to  brain-tumor  and  all 
other  encephalic  lesions,  especially  in  their  terminal  stages. 

1  "Deutsch.  Zeit.  fiir  Nervenh.,"  1897. 

2  "Deutsch.  Zeit.  fur  Nervenh.,"  Bd.  13.  ^  "Brain,"  1899. 


256  DISEASES  OF  THE  BEAIN  PROPER. 

Headache. — In  the  great  majority  of  cases  of  intracranial  tumor 
headache  is  an  early  and  persistent  symptom.  It  has  no  necessary 
relation  to  the  location  of  the  tumor,  and  is  usually  frontal  or  occipital, 
less  frequently  parietal,  or  at  the  vertex.  Sometimes  the  eyeball  is  the 
seat  of  pain.  It  usually  increases  with  the  increase  in  the  tumor's  size, 
and  is  aggravated  by  any  effort  or  condition  which  increases  arterial 
tension  and  cephalic  hyperemia.  In  character  the  headache  is  dull, 
heavv,  persistent,  often  with  great  exacerbations  ;  frequently  it  prevents 
sleep,  and  sometimes  is  of  an  intensity  that  becomes  intolerable  and 
submerges  the  patient's  intellect.  It  has  even  been  considered  the  cause 
of  death.  In  rare  instances  a  persistent,  circumscribed  headache  has 
been  found  to  conform  to  the  tumor's  location,  and,  therefore,  like  all 
diffuse  symptoms,  it  may  exceptionally  have  a  localizing  value.  In 
such  case  there  is  often  local  tenderness  on  percussion,  and  sometimes 
local  elevation  of  temperature.  In  cerebellar  growths  local  pain  and 
pain  in  the  neck,  with  retraction  of  the  head,  are  significantly  common, 
but  a  cerebellar  tumor  may  occasion  contiinious  frontal  pain.  Pain 
in  the  distribution  of  the  fifth  cranial  pair,  or  in  a  single  branch,  is  an 
indication  of  local  irritation  of  the  nerve  that  may  be  confounded  with 
the  diffuse  headache. 

General  Convulsions. — Over  one-half  of  all  cases  have  general  con- 
vulsions at  some  period  of  the  disease.  They  may  be  the  early  and 
only  manifestations  of  the  tumor,  and  indistinguishable  from  ordinary 
epilepsy,  for  which  these  patients  are  not  infrequently  treated  during 
long  periods  of  time.  More  often  the  convulsions  are  preceded  by 
headaches  and  focal  symptoms.  As  a  rule,  Jacksonian  fits  eventuate 
in  the  generalized  form,  either  by  gradation  or  alternation.  While 
these  commonly  conform  to  the  clinical  type  of  the  ordinary  epileptic 
seizure,  a  careful  study  of  them  sometimes  enables  one  to  detect  varia- 
tions from  the  type  that  have  some  significance.  The  onset  is  less 
violent  and  abrupt.  The  clonic  stage  is  likely  to  be  protracted  to 
fifteen  minutes,  a  half  hour,  or  longer ;  there  is  less  depth  to  the  coma, 
and  the  subsequent  deep  sleep  may  be  much  abridged  or  entirely  want- 
ing. They  rarely  appear  with  the  regularity  that  is  common  in  ordinary 
epilepsy.  Attacks  of  the  petit  mal  variety  are  rare  in  brain-tumor,  but 
do  occur,  while  epilepsy  presenting  major  attacks  is  rarely  without 
minor  manifestations. 

llental  Impairment — The  final  stage  of  tumor  cases  is  customarily 
marked  by  great  hebetude  and  a  stuporous  condition  that  may  increase 
into  final  coma.  In  lesser  degree  this  belittling  of  mental  vigor  is 
common  in  the  earlier  periods  of  the  disease,  with  or  without  convul- 
sions. When  the  headache  is  intense,  the  patient  is  likely  to  seek 
seclusion,  hold  his  head  in  his  hands,  and  present  a  picture  of  dejected 
indifference  that  clearly  indicates  his  mental  state.  He  replies  slowly  to 
questions  or  disregards  them  utterly.  He  can  not  think  quickly,  and  is 
sluggish  in  all  his  mental  qualities  as  well  as  in  his  physical  attributes. 
The  pulse  decreases  in  strength  and  rapidity,  respiration  is  slow  and 
shallow,  and  if  suffering  ceases  the  patient  sinks  into  a  sort  of  hibernat- 
ing sleep.      From  this  apathy,  which  may  be  more  or  less  marked,  he 


TUMORS  OF  THE  BRAIN.  257 

partially  rouses,  or  he  may  decline  into  a  more  comatose  state  and  die 
of  inanition.  The  two  prominent  characteristics  of  the  mental  state 
are  apathy  and  suffering,  which  may  be  associated  or  alternate.  So  far 
as  mental  action  can  be  elicited  it  is  usually  unclouded,  except  in  rare 
periods  of  delirium.  Something  of  this  apathy  may  be  noticed  in  com- 
paratively recent  cases,  and,  as  a  rule,  brain-tumor  patients  are  little 
worried  over  their  condition.  This  mental  change  is  most  likely  to 
be  well  marked,  and  to  appear  early  in  tumors  of  the  frontal  lobes. 
Gianelli^  reports  77  cases  of  tumor  in  the  frontal  lobes  accompanied  by 
mental  disturbance  and  20  in  which  morbid  psychic  phenomena  were 
lacking.  In  rare  cases  the  mental  symptoms  closely  imitate  the  formu- 
lated insanities,  such  as  mania,  melancholia,  and  even  hallucinatory 
paranoia.^ 

Opt'io  neuritis,  or  papillitis,  occurs  in  about  eighty  per  cent,  of  en- 
cephalic growths.  In  very  rare  instances  only  one  nerve-head,  usually 
on  the  same  side  as  the  tumor,  has  been  found  affected.  In  many  cases 
the  condition  is  more  marked  in  one  eye  than  in  the  other,  and  there  is 
some  reason  to  think  that  the  more  intense  inflammation  is  also  usually 
on  the  same  side  as  the  lesion.  (For  further  details  regarding  this 
lesion  of  the  second  cranial  nerve  reference  is  made  to  Part  II.)  In 
chronic  cases  papillitis  may  suddenly  appear,  but  a  chronic  papillitis  or 
a  very  insidious  one  does  not  belong  to  an  acute  or  rapidly  developing 
lesion.  The  natural  result  of  choked  disc  is  atrophy  of  the  optic  nerve, 
which,  therefore,  has  the  same  significance  in  the  presence  of  other 
tumor  indications.  It  must  be  borne  in  mind  that  central  vision  may 
not  be  greatly  disturbed  when  the  discs  are  distinctly  choked,  and  their 
examination  should  never  be  neglected.  This  general  symptom  of 
brain-tumor  is  very  constantly  found  in  growths  involving  the  cere- 
bellum, geniculate  bodies,  corpora  quadrigemina  and  the  brain-axis. 
It,  therefore,  has  a  slight  localizing  value. 

Vomiting. — Attacks  of  vomiting,  usually  of  the  so-called  cerebral 
variety,  without  fermentation,  nausea,  and  effort,  are  common.  They 
may  last  for  a  few  days  or  weeks ;  subside  and  recur,  and  they  usually 
attend  other  indications  of  tumor  extension  or  invasion.  Vomiting 
sometimes  threatens  death  by  inanition.  Like  choked  disc,  it  is  most 
frequent  in  tumors  involving  the  cerebellum,  especially  the  middle  lobe 
and  the  corpora  quadrigemina. 

Vertigo  occurs  with  brain-tumors  in  all  locations,  but  especially  in 
the  cerebellar  and  frontal  regions.^  It  is  a  vague  distress  in  some 
cases  or  a  feeling  of  being  submerged  or  of  mere  darkness  and  sinking, 
and  may  be  paroxysmal  or  constant.  In  addition,  brain-tumor  may 
give  rise  to  ocular  vertigo  by  involvement  of  the  motor  oculi  nerves, 
and  to  auditory  vertigo  by  implicating  the  eighth  nerve.  In  cerebellar 
tumors  affecting  its  peduncles,  especially  the  middle  one,  there  may  be 
forced  movements  and  attitudes.  In  these  combinations  vertigo  fur- 
nishes a  valuable  localizing  indication.     In  some  cases  it  is  an  epileptic 

1  "II  Policlinieo,"  Jvily  15,  1897. 

2  Bayerthal,  "  Miinch.  med.  Wochens.,"  1899. 

3  Bi-iins,  "  Wieii.  klin.  Runds.,"  1897,  No.  46. 
17 


258  DISEASES  OF  THE  BRAIN  PROPER. 

equiv^alent.  It  sometimes  is  attended  by  vomiting.  It  may  prevent 
the  patient's  rising  from  recumbency,  or  cause  him  to  lie  down  if  stand- 
ing. Ordinarily  he  grasps  an  object  for  support,  and  is  soon  over  the 
attack. 

Focal  Symptoms. — The  symptoms  due  to  the  presence  of  a  new 
growth  or  other  lesion  in  special  brain  regions  have  been  discussed  at 
length  in  the  opening  chapters  of  this  part.  They  consist  usually  of 
unilateral  spasuns  confined  to  the  face,  to  a  limb,  or  to  a  segment  of  a 
limb;  of  mono2:)legias;  of  paresthesias  of  functional  distribution;  oi  hemi- 
anopsia or  other  sensory  disturbances  ;  of  aphasia ;  of  stereoagnosis 
and  of  impairment  of  the  cranial  nerves.  They  are  variously  combined 
as  associated  anatomical  structures  happen  to  be  involved.  They  ad- 
vance with  the  tumor's  growth,  and  change  as  irritation  yields  to  de- 
struction. They  thus  vary  indefinitely  in  different  cases,  and  usually 
present  numerous  modifications  in  the  clinical  history  of  any  given  case. 
To  the  Jacksonian  fit,  whether  the  spasmodic  or  the  sensory  features 
predominate,  most  attention  has  been  directed,  as  it  points  with  detinite- 
ness  to  the  locus  of  greatest  and  usually  of  initial  disturbance.  To 
avoid  needless  repetition,  the  reader  is  again  referred  to  the  previous 
chapters  on  cerebral  localization  and  diseases  of  the  cranial  nerves. 
Hallucinations  of  the  special  senses  occurring  with  convulsions  or  inde- 
pendently sometimes  are  caused  by  tumors  situated  in  the  corresponding 
area  or  influencing  it  more  or  less  directly. 

Topical  Symptoms. — The  location  of  a  new  growth  near  the  surface 
of  the  brain,  so  that  it  impinges  upon  the  meninges  or  invades  them, 
is  sometimes  attended  by  topical  conditions  of  some  significance. 
Local  and  persistent  tenderness,  heat,  and  headache  may  be  thus  induced. 
In  the  rare  cases,  where  the  cranial  bones  are  perforated  by  erosion, 
palpation  may  detect  the  bony  opening  and  the  tumor  mass.  Invasions 
of  the  orbit,  pharynx,  and  nasal  cavities  are  open  to  ready  investiga- 
tion. Percussion  over  large  tumors  superficially  placed  may  demon- 
strate a  changed  pitch  in  the  resulting  note.^ 

Multiple  tumors  may  furnish  many  diverse  and  conflicting  symptoms, 
but  usually  one,  owing  either  to  its  situation  or  major  size,  gives  a  pre- 
ponderance of  manifestations. 

Course. — The  majority  of  cases  of  brain-tumor  are  clinically  of 
insidious  onset,  progressive  development,  and  fatal  termination  in  a 
cachectic  state,  induced  by  the  gradually  increasing  intracranial  pres- 
sure and  the  extinction  of  cerebral  functions.  The  ordinary  duration 
is  from  a  few  months  to  three  years.  The  lethargy,  stupor,  and  coma 
of  late  stages  are  frequently  aggravated  by  paralytic  features,  and  con- 
tinuous vomiting  may  defeat  all  attempts  at  nourishment.  While  this 
is  true  of  the  larger  number  of  cases,  there  are  numerous  exceptions. 
Sometimes  the  first  pronounced  symptom  is  an  apoplectic  attack  which  may 
carry  off  the  patient  at  once.  The  apoplexy  is  brought  about  by  a  cere- 
bral hemorrhage,  due  to  erosion  of  a  vessel,  or  sometimes  to  the  tumor 
pressure  obliterating  an  artery  by  thrombosis  or  by  its  mere  mechanical 
effect.      In  the  softer  growths,  notably  gliomata,  hemorrhage  into  the 

^  Bruns,  loc.  cU. 


TUMORS  OF  THE  BRAIN.  259 

mass  may  take  place  and  secondarily  affect  the  cerebral  structure. 
Hemorrhage  into  the  substance  of  a  tumor  may  also  directly  induce 
the  apoplectic  state  and  lead  to  a  fatal  termination.  Gerhardt  states 
that  in  this  accident  the  initial  fall  of  temperature  that  attends  an 
ordinary  cerebral  hemorrhage  does  not  occur.  Some  tumors  give 
rise  to  no  symptoms  and  are  only  detected  after  death  from  intercurrent 
disease. 

The  nature  of  the  growth  in  some  degree  determines  the  rapidity 
of  the  evolution  of  the  case,  but  in  turn  is  subject  to  its  localization. 
Tubercle,  fibroma,  cerebroma,  sarcoma,  syphiloma,  carcinoma,  and 
glioma,  in  ascending  order,  increase  in  the  rapidity  with  which  they 
influence  the  brain-structure.  The  more  rapid  the  growth,  the  more 
rapid  the  development  of  pressure  and  the  more  quickly  does  destruc- 
tion advance.  Tuljercles,  however,  furnish  some  of  the  most  rapid  as 
well  as  some  of  the  most  dilatory  cases.  A  fatality  is  imminent  in  pro- 
portion as  the  growth  recedes  from  the  cortex  and  approaches  the 
medulla  in  location.  In  the  latter  position  or  in  its  neighborhood,  as 
in  the  basal  ganglia,  the  pons  and  cerebellum,  a  small  and  comparatively 
benign  growth  may  induce  a  rapid  course  and  early  fatal  termination. 

The  succession  of  symptoms  is  again  determined  by  the  nature  and 
the  location  of  the  growth.  Headache  is,  of  all  the  diffuse  or  general 
symptoms,  commonly  the  earliest,  and  optic  neuritis  usually  follows  in  a 
few  months.  Spasms  depend  on  the  amount  of  irritation  of  the  corti- 
cal structures,  and  paralysis  on  their  destruction  or  the  cutting  of  the 
motor  paths.  General  convulsions,  as  pointed  out,  are  often  early  feat- 
ures ;  they  especially  precede  the  paresthesias  and  palsies.  By  the  ex- 
tension of  the  growth  invasion  symptoms  are  set  up  (see  p.  186),  and 
a  widening  of  motor  and  paralytic  phenomena  follows  in  anatomical 
order.  Tubercular  and  carcinomatous  growths,  being  usually  secondary 
manifestations,  bear  with  them  the  possibility  of  a  rapid  downward 
course  from  conditions  outside  the  cranium.  In  addition,  a  tubercular 
neoplasm  is  likely  to  set  up  a  diffuse  ttibercular  meningeal  infection  that 
may  promptly  destroy  the  patient.  A  syphiloma  in  the  same  way  may 
be  attended  by  a  wide-spread  syphilitic  meningitis. 

Diagnosis. — In  a  case  presenting  cerebral  indications  and  giving 
rise  to  the  suspicion  of  tumor,  the  diagnosis  is  much  facilitated  by  a 
careful  arrangement  of  the  symptoms  in  the  order  of  their  develop- 
ment. A  nttmber  of  problems  are  presented:  (1)  Is  there  a  tumor? 
(2)  Where  is  it  located  ?  (3)  What  is  its  size  ?  (4)  What  is  its  nature  ? 
(5)  Is  it  operable  ? 

To  the  solution  of  the  first  question,  is  there  a  tumor,  a  definite 
answer  can  usually  be  given.  Bruns  says  tumor  may  be  diagnosed  in 
eighty  per  cent,  of  all  cases.  After  taking  into  consideration  the  evo- 
lution of  the  case,  the  focal  or  localizing  symptoms  are  the  most  reliable 
data,  but  are  strongly  confirmed  or  rendered  positive  by  the  presence  of 
the  diffuse  indications.  Localized  fits  may  be  presented-  by  ordinary 
epilepsy,  but  if  headache,  cerebral  vomiting,  vertigo,  and  choked  disc, 
one  or  all,  are  added,  the  probability  of  tumor  is  enhanced.  Should 
now  the  local  spasm  be  followed  by  persistent  paresis  or  paresthesia  in 


260  DISEASES  OF  THE  BEAIN  PROPER. 

the  same  locality,  a  positive  statement  is  allowable.  In  the  same  way  a 
hemianopsia  or  aphasia,  following  or  associated  with  generalized  or  lim- 
ited convulsions  and  attended  by  some  or  all  of  the  diffuse  symptoms, 
permits  a  diagnosis  of  tumor. 

The  clinical  history  of  the  case  is  important,  as  by  it  and  its  special 
symptoms  we  have  to  diiferentiate  tumor  from  acute  and  chronic  men- 
ingitis, with  which,  indeed,  it  may  in  some  cases  be  complicated.  The 
early  and  persistent  headache  is  common  to  both,  but  tumor  presents,  as 
a  rule,  a  choked  disc,  while  meningitis  has  a  neuroretinitis.  Meningitis, 
even  of  the  tubercular  form,  is  of  comparatively  rapid  development, 
while  tumor  commonly  requires  months.  In  meningitis  the  motor 
symptoms  are  usually  bilateral,  as  contrasted  with  the  one-sidedness  of 
tumor  disturbance.  It  will  be  recalled  that  a  latent  cerebral  abscess 
may  present  all  the  indications  of  a  tumor,  which  indeed  it  is,  and  it 
requires  no  differentiation  aside  from  the  fact  that  it  offers  a  better 
operative  outlook.  The  cerebral  palsies  of  childhood  and  general  j^aresis 
in  adults  have  been  confounded  with  tumor,  but  a  careful  scrutiny  of 
the  case,  with  a  knowledge  and  mindfulness  of  these  maladies,  will 
obviate  error.  The  tumors  which  present  a  sudden  apoplectic  onset 
may  be  confounded  with  cerebral  hemorrhage  or  softening.  Here  the 
ordinary  antecedents  of  vascular  disease  and  the  arterial  condition  pre- 
sented furnish  a  strong  presumption  of  vascular  accident,  and  serve 
to  a  reasonable  degree  to  exclude  tumor,  if  the  diffuse  symptoms  of 
tumor  are  lacking.  It  will,  however,  be  borne  in  mind  that  a  brain- 
tumor  may  bring  about  vascular  disease,  and  that  hemorrhage  into 
gliomatous  and  other  soft  growths  may  produce  apoplectic  states  which 
would  be  further  favored  by  atheromatous  conditions  of  the  blood- 
vessels. The  diagnosis  must  rest  on  the  antecedent  and  sometimes  on 
the  subsequent  history  of  the  case. 

There  is  reason  to  hope  that  -^dagraphy  may  give  aid  in  the  diagnosis 
of  brain  tumors.  Obici  and  Ballici  ^  were  able  to  thus  demonstrate  a 
sarcoma  in  a  cadaver.  The  writer,^  in  two  cases,  and  Mills, ^  in  two 
cases,  have  obtained  similar  results  during  life. 

The  second  question,  of  location,  is  answered,  if  answerable  at  all, 
by  a  consideration  of  the  focal  and  topical  symptoms  of  the  case  and 
the  localizing  bearing  of  the  diffuse  symptoms  that  are  presented.  The 
absence  of  focal  symptoms  points  to  the  regions  of  latent  lesions  in  the 
frontal,  temporosphenoidal,  and  post|3arietal  regions,  especially  on  the 
right  side. 

It  is  necessary  to  answer  the  second  question  before  the  third  can  be 
approached,  as  we  can  only  relatively  estimate  the  size  of  a  tumor  by 
knowing  its  location  and  the  anatomical  regions  invaded.  To  this  end 
the  sequence  of  developments  is  our  greatest  aid.  Invasion  symptoms 
enable  us  to  trace,  especially  in  the  motor  cortex,  the  gradual  growth 
of  a  tumor,  and  in  some  directions  to  indicate  its  extent.  If 
this  can  be  done  on  a  portion  of  the  periphery,  a  knowledge  of  the 
symptoms  that  would  arise  by  the  tumoi^s  extension  in  the  opposite 

1  "  Rivista  di  Patbologica,'"  Oct.,  1R97.     -  ''  Amer.  Jour.  Med.  Sciences,'"  Feb.,  1?99. 
^  "Phila.  Med.  Jour.,"  Feb.  24,  1902. 


TUMORS  OF  THE  BRAIN.  261 

direction  may  enable  us  to  say  whether  or  not  such  centers  or  pathways 
have  been  seriously  invaded.  It  is  evident  that  only  a  very  inexact 
measurement  can  be  made,  and  this  is  especially  true  if  the  growth  is 
situated  in  the  neighborhood  of  the  latent  lesion  territories. 

To  the  fourth  question,  what  is  the  nature  of  the  tumor,  a  posi- 
tive answer  can  never  be  given,  unless  there  is  an  external  portion  of 
the  tumor,  but  a  strong  probability  is  frequently  forthcoming.  In  this 
relation  the  age,  the  diathesis,  the  history  of  previous  illness,  the  pres- 
ence of  various  diseases,  the  location  of  the  tumor,  its  rate  of  develop- 
ment, and  the  effect  of  treatment  aid  us.  In  childhood,  tubercle,  glioma, 
sarcoma  are  most  frequent ;  in  adults,  the  tirmer  tumors  and  syphiloma  ; 
in  advanced  years,  carcinomata.  The  presence  of  tuberculosis,  carci- 
noma, parasitic  cysts,  or  syphilis  gives  much  weight  to  the  supposition 
that  the  brain-lesion  is  of  a  similar  character.  Tubercle  and  glioma 
favor  the  pons  and  cerebellum.  Syphilis  favors  the  pons,  basilar  area, 
and  cortex,  but  is  rare  in  the  cerebellar  white  matter  and  the  centrum 
ovale.  Fibroma  and  glioma,  being  interstitial  growths,  occur  in  the 
deep  structures.     Sarcoma  mostly  occurs  in  the  ventricles  or  meninges. 

A  rapid  onset,  followed  by  a  stationary  period,  speaks  for  tubercle, 
especially  in  the  first  half  of  life.  Glioma  and  sarcoma  are  of  insidious 
and  steady  development.  Apoplectic  seizures  in  tumor  cases  usually 
mean  glioma.     Syphilis  provokes  a  rapid  onset  and  course. 

Only  syphilitic  tumors  are  permanently  affected  for  good  by  treat- 
ment, but  it  must  be  said  with  due  emphasis  that  the  iodids  are  capable 
of  apparently  checking  sarcomatous  growths  and  frequently  cause  tempo- 
rary and  misleading  benefit  in  all  forms  of  tumor,  probably  by  favoring 
the  removal  of  the  circumscribing  edema. 

The  fifth  question  concerns  the  possibility  of  surgical  removal. 
From  the  large  statistics  compiled  by  Starr,  and  from  later  additional 
data,  it  can  be  stated  that  not  more  than  seven  times  in  a  hundred  cases 
of  brain-tumor  is  the  growth  operable.  Unless  the  neoplasm  lies  on  or 
in  the  convexity  of  the  cerebral  hemispheres  it  is  not  readily  approach- 
able. Cerebellar  tumors  have  been  removed,  but  nearly  always  with 
fatal  result;  yet  it  seems  reasonable  to  hope  that  better  fortune  may 
follow  in  carefully  selected  cases.  Piollet  ^  tabulates  forty-eight  cases 
of  cerebellar  tumor  surgically  removed.  In  twenty  death  promptly 
ensued  ;  in  sixteen  improvement  with  subsequent  death  from  recurrence 
of  the  growth  ;  in"  four  almost  complete  cure,  and  apparently  complete 
cure  in  one  only.  Cerebellar  cysts  offer  a  good  operative  prospect. 
The  basilar,  pontine,  and  medullary  regions  are  out  of  the  operative 
field.  Cysts  and  old  abscesses  are  readily  drained.  Sarcomata  can 
usually  be  enucleated,  tubercles  and  fibroid  tumors  can  be  shelled  out, 
but  glioma,  from  its  infiltrating  character,  and  other  similar  growths 
can  never  be  entirely  removed,  and  grow  again  if  the  attempt  is  made. 

Prognosis. — If  ninety-three  per  cent,  of  brain-tumors  are  inoper- 
able and  syphiloma  is  only  partially  amenable  to  medicinal  treatment, 
the  gravity  of  the  disease  is  apparent.  The  great  majority  of  cases 
run  their  course  within  three  years,  though  slow-growing  neoplasms 
1  "Arch.  Provinc.  de  Chirurg.,"   1901. 


262  DISEASES  OF  THE  BRAIN  PROPER. 

may  exist  almost  an  indefinite  time  or  may  only  furnish  a  post-mortem 
surprise.  The  outlook  turns  upon  the  nature  of  the  growth  and  the 
associated  clinical  manifestations.  The  possibility  of  sudden  death 
should  not  be  overlooked,  especially  in  tumors  located  in  or  near  the 
brain-axis. 

Treatment. — The  management  of  brain-tumors  is  of  two  sorts  : 
(1)  That  directed  to  the  tumor  itself,  and  (2)  that  to  the  general  physical 
condition.  Removal  of  the  tumor  by  operation  is  possible  in  a  small 
number  of  cases,  and  should  be  done  whenever  indicated  and  the  condi- 
tions are  otherwise  favorable.  This  surgical  proceeding  in  the  hands  of 
competent  men  has  secured  some  brilliant  results  and  saved  and  pro- 
longed life.  Oppenheim  states  that  good  results  have  been  obtained  in 
about  one-half  of  all  well-selected  cases.  Even  in  inoperable  tumors 
a  wide  opening  of  the  skull  has  relieved  pressure,  has  benefited  the 
mental  condition,  stopped  the  headache,  and  caused  the  choked  disc  to 
subside.  It  is  indicated  in  at  least  five-sixths  of  all  cases,  according  to 
Knapp.i  Indeed,  in  some  cases  it  has  seemed  to  cause  the  tumor 
to  recede.  As  above  indicated,  cerebellar  tumors  are  not  favorable 
for  operation.  The  harder  and  slower  growing  sorts  of  brain  neo- 
plasms offer  the  best  operative  results.  Tubercle,  sarcoma,  and 
fibroma,  or  their  varieties,  can  be  removed  en  masse,  while  the  limits 
of  infiltrating  growths  are  difficult  to  distinguish  and  complete  removal 
is  practically  impossible.  Cysts  and  abscessefe  can  be  evacuated,  and  if 
the  secreting  wall  is  removed,  a  practical  cure  follows.  Should  the  cyst 
be  due  to  degeneration  of  a  sarcomatous  growth,  the  probability  of  a 
return  is  very  great. 

In  syphilitic  growths  intensive  treatment  with  mercury  and  the 
iodids  usually  produces  prompt  improvement.  This  goes  so  far  that 
many  cases  are  alleged  to  be  cured,  and  the  shriveled  remains  of  a 
syphiloma  have  been  found  post  mortem  to  testify  to  the  efficacy  of 
treatment  and  the  precision  of  diagnosis.  A  large  degree  of  reservation, 
however,  should  be  maintained  in  every  syphilitic  case.  As  a  rale,  the 
cure  is  not  complete.  Some  residuum  of  disability  can  usually  Vje  de- 
tected, and  a  constant  tendency  for  the  syphilitic  process  to  reappear 
during  the  rest  of  life  too  frequently  keeps  these  patients  fighting  the 
disease  as  long  as  they  live.  In  order  to  secure  the  best  results,  both 
mercury  and  iodid  should  be  used,  either  together  or  alternately,  de- 
pending upon  the  urgency  of  the  condition,  and  both,  with  careful 
guarding,  should  be  pushed  to  the  limit  of  toleration.  Explicit  direc- 
tions for  the  treatment  of  syphilis  will  be  found  in  the  chapter  on  Syph- 
ilitic Diseases  of  the  jS^ervous  System,  Part  VI. 

As  tumors  of  all  varieties  have  shown  at  least  temporary  improve- 
ment under  the  use  of  antisyphilitics,  the  practitioner  must  be  guarded 
in  drawing  inferences  from  such  therapeutics,  and  not  allow-  himself  to 
talce  too  favorable  a  view  of  the  case  when  this  occurs.  It  is  an  estab- 
lished rule  to  use  specific  treatment  in  all  cases  of  brain-tumor  where 
there  is  a  shadow  of  a  doubt  as  to  their  character.  If,  after  six  weeks 
■of  vigorous  treatment  no  benefit  is  obtained,  the  lesion  is  pretty  surely 

1  "Boston  Med.  and  Surg.  Jour.,"   Oct.,  1899. 


UYniWCEPHALUS.  263 

not  syphilitic.  Should  ini])roveiii<'iit  take  place,  a  continuance  of  treat- 
ment should  be  persisted  in  until  all  symptoms  have  practically  disap- 
peared. A  return  of  former  symptoms  or  further  develoj)ment  of 
tumor  indications  in  the  face  of  specific  treatment  practically  demon- 
strates the  non-syphilitic  character  of  the  disease.  Horsley  contends 
with  much  reason  that  when  attackable,  even  syphilomata  should  be 
treated  surgically  after  a  fair  trial  of  specific  medication,  and  CoomVjs 
Knappi  found  nine  out  of  ten  such  operations  to  have  been  successful. 
The  patient's  general  condition  will  require  constant  attention. 
Tuberculous  and  other  cachectic  states  have  their  own  requirements. 
The  headache  can  often  be  relieved  for  a  time  by  Ijrisk  cathartics  and 
hot  baths.  Antipyrin  and  other  coal-tar  analgesics  often  control  the 
headache  for  a  time.  The  opiates  are  frequently  powerless  except  in 
•extreme  doses,  and  their  use  should  be  postponed  to  the  last  possible 
moment.  Vomiting  yields  best  to  nerve  sedatives,  such  as  the  bromids, 
and  to  measures  like  hot  baths  and  mustard  foot-baths,  calculated  to 
decongest  the  cerebral  circulation.  In  rare  cases  it  is  quite  unmanage- 
ble,  even  by  morphin,  and  may  lead  to  rapid  inanition  and  death  from 
exhaustion.  Convulsions  can  usually  be  restrained  by  the  Ijromids.  The 
continued  use  of  bromids  and  antipyrin  will  be  found  especially  valu- 
able in  these  cases,  and  a  flagging  heart  may  be  protected  by  caffein  or 
strychnin.  The  optic  neuritis  can  be  benefited  in  syphilitic  cases  by 
medicinal  treatment.  In  other  sorts  of  growth  it  is  frequently  benefited 
by  operation.  Repeated  spinal  puncture  may  also  yield  palliative  results. 
When  optic  atrophy  has  once  occurred,  it  is  permanent.  Finally,  by 
nutritious  diet,  baths,  massage,  and  general  measures  the  strength  of  the 
patient  is  supported  and  life  prolonged. 


CHAPTER  XII. 
HYDROCEPHALUS. 

Hydrocephalus  is  a  term  loosely  used  to  designate  any  undue 
;amount  of  watery  fluid  within  the  skull,  and  in  such  a  sense  is 
synonymous  with  dropsy  of  the  brain.  Tubercular  meningitis,  fre- 
quently called  acute  hydrocephalus  by  older  writers,  is  not  the  condi- 
tion in  question.  Nor  are  we  now  to  consider  the  compensatory  increase 
of  cerebrospinal  fluid  occurring  in  the  convolutional  shrinkage  of  old  age, 
or  in  the  cerebral  atrophy  of  dementia,  or  in  porencephalic  or  anence^ihalic 
defects.  The  question  does  not  pertain  to  the  increase  of  fluid  which 
marks  acute  meningitis  or  tubercular  meningitis,  or  to  the  edematous 
state  that  frequently  attends  cerebral  tumors.  Attention  has  also  been 
called  in  the  proper  place  to  ventricular  distention  resulting  from 
tumors  situated  in  the  posterior  cranial  fossse,  which  mechanically  block 
the  venous  return  through  the  veins  of  Galen  and  the  straight  sinus. 
It  is  desired  to  restrict  the  term  hydrocephalus  to  a  congenital  or  acquired, 
acute  or  chronic  condition  marked  by  great  increase  in  the  amount  of 
^cerebrospinal  fluid  within  the  skull  attended  by  compression  of  the  brain. 
1  "  Boston  Med.  and  Surg.  Jour.,"  Oct.,  1899. 


264  DISEASES  OF  THE  BRAIN  PROPER. 

In  some  cases  it  is  entirely  ventricular,  constituting  internal  hydro- 
cephalus;  in  others  it  is  subdural,  constituting  external  hydrocepha- 
lus; but  usually  both  the  subdural  and  the  ventricular  spaces  are  dis- 
tended. 

Etiology. — The  causation  of  hydroceplialus  is  obscure.  Some 
families  seem  to  be  marked  by  a  hereditary  tendency  to  it,  as  shown  by 
several  cases  occurring  in  the  same  or  succeeding  generations.  Heredi- 
tary syphilis  has  for  long  been  thought  to  be  a  competent  cause,  but 
in  many  cases  it  can  be  excluded  with  a  reasonable  certainty.  Its 
causal  relation  is  supported  by  Heller  ^  and  by  Titoraanlio  ^  in  careful 
studies.  Alcoholism  on  the  part  of  the  parents  is  also  supposed  to  have 
some  part  in  producing  the  congenital  variety,  and  is  doubtless  active  in 
some  of  the  late  adult  cases.  Traumatism  after  birth  has  produced  it, 
and  it  has  been  noted  as  a  sequel  of  cerebrospinal  meningitis.  ^  Quincke 
describes  a  form  of  acute  serous  meningitis  the  symptoms  of  which  do  not 
vary  materially  from  those  of  the  ordinary  infectious  variety,  but  which 
is  marked  by  the  rapid  production  of  subdural  hydrocephalus  and  great 
intracranial  pressure. 

Morbid  Anatomy. — In  congenital  cases  and  in  those  occurring  be- 
fore the  cranial  bones  are  firmly  united  the  head  is  enlarged,  sometimes 
to  vast  proportions.  The  cranial  hones  are  usually  reduced  in  thickness, 
often  to  that  of  paper,  the  diploe  being  absent.  At  the  same  time  they 
are  frequently  much  broadened.  The  sutures  are  patent,  or  super- 
numerary bones  are  commonly  found  if  synostosis  has  taken  place  after 
the  disease  has  been  present  for  some  time.  The  frontal,  occipital,  and 
squamous  portions  of  the  temporal  bones  are  displaced  outward.  The 
parietals  conform  to  the  globular  shape  of  the  head. 

The  amount  of  jluid  may  be  incredibly  increased,  and  as  much  as 
three  gallons  has  been  noted  in  a  very  extreme  case  of  long  standing. 
It  is  a  colorless  fluid  of  low  specific  gravity,  and  quite  similar  to  chronic 
elfusions  in  other  fibroserous  cavities  and  closely  resembles  normal 
cerebrospinal  fluid. 

The  principal  distention  is  usually  in  the  lateral  ventricles^  which 
bulge  in  all  directions  and  stretch  out  their  cerebral  walls  into  a  thin 
lining  for  the  enlarged  cranial  cavity.  The  basal  ganglia  are  often 
compressed  and  flattened.  The  ventricular  lining  is  found  usually,  if 
not  always,  in  a  thickened,  granular,  hypertrophic  condition.  It  may 
reach  a  thickness  of  half  an  inch.  The  choroid  plexuses  are  corre- 
spondingly enlarged.  This  apparent  ependyraitis  often  serves  to  occlude 
the  ventricular  aqueducts,  so  that  the  third  and  fourth  ventricles  may 
not  share  in  the  dilatation  or  it  may  be  confined  to  one  lateral  cavity. 
In  about  one-half  of  the  cases  connection  with  the  spinal  spaces  i& 
obliterated.  In  the  congenital  and  adult  cases  it  is  common  for  all  the 
cerebral  ventricles  and  the  cord  to  be  involved.  When  the  third  and 
fourth  ventricles  are  affected,  the  optic  tracts  suffer  and  optic  atrophy  is 
common.      At  the  same  time  the  cerebellum,  pons,  and  medulla  are 

1  "Deut.  med.  Wochens.,"  June  30,  1R92. 

*  Trans.  Section  on  Diseases  of  Children,  International  Med.  Cong.,  Eome,  1894. 

*  E.  P.  Joslin,  "Am.  Jour.  Med.  Sci.,"  Oct.,  1900,  eight  cases. 


HYDEUVErJJALUS.  265 

defectively  developed.  The  meninges  niay  show  little  or  no  change. 
After  cranial  nolidification  the  anatomical  conditions  are  modified  by  the 
resistant  character  of  the  sknll.  The  amonnt  of  fluid  is  necessarily  less, 
but  the  pressure  falls  more  directly  upon  the  cerebrum. 

Symptoms. — Hydrocephalic  enlarr/ement  of  the  head  sometimes  ren- 
ders birth  difficult  or  requires  the  use  of  the  perforator  before  extraction 
can  be  accomplished.  In  other  and  a  majority  of  the  cases  the  condition 
is  insignificant  or  unnoticed  at  birth,  and  appears  during  the  first  year  of 
life,  especially  during  the  first  six  months.  The  head  gradually  or  raj)- 
idly  enlarges  in  all  its  diameters  and  measurements.  An  increase  " 
the  circumference  of  the  head  at  a  rate  of  a  centimeter  daily  has  b('( 
noted,  but  usually  it  requires  several  weeks  for  that  amount  of  enlarg 
ment  to  take  place.  The  outline  of  the  skull  is  globular  and  ma\ 
overhang  the  face,  ears,  and  occiput,  which  are  not  correspondingly  eii- 
larged.  The  internal  pressure  is  manifest  at  the  bulging  fontanels, 
which  are  increased  in  size  and  connected  by  wide-open  sutures.  The 
return  cirGulatlon  of  the  cerebrum  is  impeded,  and  the  collateral  veins  in 
the  scalp  and  face  become  distended  and  strikingly  apparent.  From  the 
outward  tilting  of  the  frontal  bones  the  orbits  are  directed  downward  and 
the  ocular  globes  are  often  maintained  in  the  same  direction,  even  to  such 
a  degree  that  the  cornea  is  only  seen  with  difficulty.  Optic  atrojjhy  and 
blindness  are  frequent.  Nystagmus  and  strabismus  are  common.  Fluc- 
titation  is  readily  obtained  on  palpation,  and  the  head,  in  extreme  cases, 
may  be  translucent. 

The  hydrocephalic  child  shows  little  ac- 
tivity, can  not  raise  its  head  sometimes,  or  only 
does  so  with  the  aid  of  its  hands.  There  is  a 
tendency  to  peevishness  and  restlessness  or 
somnolence  and  coma,  broken  by  generalized 
convulsions  and  a  frequently  repeated  distressed 
cry.  Older  children  complain  of  pain  in  the 
head.  The  body  and  limbs  suffer  in  their  nu- 
trition and  are  unequal  to  the  task  of  holding 
up  the  head  and  trunk.  In  some  cases  spasti- 
city develops  in  the  limbs,  especially  in  the  ,  i 
lower  ones,  and  some  paralytic  loss  of  power  is  /  ^  | 
frequently  noted.  Vomiting  is  frequent  and 
may    be    provoked    by    movements    or    much           J\^-  loo.— chronic  hydio- 

,       ', ..  '-  ''  cephalus    in    a    culld    of    four 

handlmg.  yeais.     Circumfereuceof  head, 

If  not  rapidly  fatal  by  exhaustion,  convul- 
sion, coma,  or  syncope,  the  disease  may  come 

to  a  standstill  or  proceed  with  such  slowness  that  the  child  is  enabled, 
in  some  defective  measure,  to  maintain  growth  and  develop  its  physical 
and  mental  faculties.  These  are  both  invariably  much  retarded,  so  that 
the  body  is  dwarfish  and  in  great  disproportion  to  the  cephalic  enlarge- 
ment. The  occasional  cases  that  live  to  mature  yeai\s  are  more  or  less 
imbecile,  clumsy,  and  physically  defective,  though  a  slight  degree  of 
hydrocephalus  is  not  incompatible  with  mental  brilliancy.  Many  cases 
of  marked  dolichocephalia  in  adults  with  beetling  brow  and  salient  oc- 
ciput prove  the  possibility  of  recovery. 


266  DISEASES  OF  THE  BRAIN  PROPER. 

When  hydrocephalus  is  acquired  subsequent  to  cranial  synostosis,  the 
symptoms  are  vague,  and  only  rarely  can  the  condition  be  deciphered 
ante  mortem.  The  indications  are  not  unlike  those  of  tumor.  It 
usually  follows  head  injury.  Mental  impairment,  especially  of  memory, 
vertigo,  vomiting,  insomnia,  headache,  convulsions,  and  rigidities  are 
encountered.  Hemiplegia  is  rather  frequent.  The  pupils  are  dilated 
and  stationary.  Strabismus  is  common.  Periods  of  coma  are  frequent. 
Death  may  be  sudden  or  follow  coma. 

Course. — The  disease  presents  a  varied  course.  The  congenital 
cases  may  run  rapidly  to  a  fatal  termination  in  a  few  weeks,  while  others 
come  to  a  standstill  and  allow  a  fair  degree  of  adult  development  and 
a  comparatively  long  life.  As  a  rule,  marked  hydrocephalic  cases  do 
not  reach  maturity,  but  give  out  at  adolescence  and  puberty,  if  not 
sooner  carried  off  by  convulsions  or  comatose  conditions  referable  to  the 
intracranial  pressure.  It  is  extremely  rare  for  them  to  live  beyond 
thirty.  In  the  acquired  adult  cases  a  fatal  termination  is  usual  within 
two  or  three  years,  and  often  sooner. 

Diagnosis. — The  diagnosis  in  infantile  cases  can  hardly  offer  any 
difficulty  if  the  tendency  to  cephalic  enlargement  is  noted.  The  globular 
shape  of  the  head  should  distinguish  it  from  the  rectangular  conforma- 
tion of  rickets  with  the  enlarged  and  squared  forehead  and  prominent 
frontal  eminences,  though  patency  of  fontanels  is  usually  present 
in  both.  The  appearance  of  rickety  conditions  in  the  long  bones  and 
at  the  costal  extremities  is  also  significant.  The  two  conditions,  how- 
ever, may  be  associated.  Before  the  head  shows  much  or  any  abnormal 
increase  it  is  difficult  to  exclude  meningitis,  which  may,  indeed,  be  the 
causal  condition.     The  treatment,  however,  is  very  similar  in  both. 

In  adults  the  diagnosis  is  well-nigh  impossible,  and  when  suspected 
can  only  be  confirmed  by  an  autopsy.  A  condition  acquired  after  com- 
plete union  of  the  cranial  bones,  commencing  anywhere  from  five  to  fifty 
years  of  age, — hyperostosis  cranii, — may  at  first  sight  mislead.  The  his- 
tory will  at  once  differentiate  it.  Notable  hydrocephalic  enlargement 
must  begin  in  very  early  life.  In  hyperostosis  cranii  the  size  of  the 
head  is  due  to  a  thickening  of  the  cranial  bones,  and  the  bones  of  the 
face  and  spine  are  usually  affected  in  a  similar  way.  The  enlarged 
head  of  acromegalia  may  be  distinguished  by  its  late  development  and 
the  associated  deformities  of  face,  hands,  and  feet. 

Prognosis. — The  prognosis  for  life  is  always  grave.  The  great 
majority  of  cases  die  within  a  year.  A  few  with  enormous  heads  live 
for  a  few  years,  and  in  those  marked  by  a  stationary  condition  life  is  still 
usually  much  shortened.  The  outlook  for  mentality  is  also  darkened, 
but  must  be  estimated  for  the  individual  case.  Mental  enfeeblement 
is  the  rule,  and  this  may  be  mere  childishness  or  pronounced  imbecility. 
Epileptoid  attacks  are  of  serious  import  both  as  to  life  and  mental 
development. 

Treatment. — The  treatment  of  these  cases  is  medical  and  surgical. 
Mercurial  inunctions  to  the  head  and  the  use  of  iodine  preparations  have 
long  been  practised.  It  is  probable  that  some  of  the  good  results 
attributed  to  these  measures  are  not  due  to  their  alleged  stimulation  of 


HYDROCEPHALUS.  267 

absorption,  but  to  their  influence  on  a  sy})hilitic  factor.  As  a  rule, 
they  are  of  little  value,  and  should  only  be  used  when  there  is  suspicion 
of  specific  taint.  Catharsis  and  other  violent  elimination  is  to  be 
discountenanced,  as  it  only  serves  to  exhaust  the  patient's  diminished 
strength.  When  the  process  is  active,  the  application  of  cold  to  the  neck 
and  head  by  ice-bags  or  flexible  coils  is  valuable.  A  slight  mercurial 
action,  preferably  by  calomel  in  minute  and  frequent  doses,  should  be 
used.     Convulsions  require  sedatives,  especially  bromids. 

Strapping  the  head  with  surgeons'  plaster  or  the  application  of  elastic 
caps  and  bandages  have  been  advocated,  but  are  usually  intolerably  pain- 
ful and  aggravate  the  pressure  conditions.  Repeated  tappings  through 
the  fontanels  or  by  lumbar  puncture  have  been  employed  with  varying 
results.  Occasionally  they  have  seemed  to  be  successful,  but  lumbar 
puncture  will  be  fruitless  in  at  least  half  of  the  cases  owing  to  the  lack 
of  communication  between  the  brain  and  cord  spaces.  ^  Only  a  moderate 
quantity  of  fluid  should  be  withdrawn  at  a  time,  and  the  strictest  anti- 
septic precautions  must  be  employed.  Some  have  ventured  to  withdraw 
fluid  and  inject  iodine  solutions  as  in  the  treatment  of  hydrocele,  but  the 
plan  can  not  be  advocated.  Too  frequently  the  punctures  result  in  a 
meningitis  that  carries  off  the  patient.  Plans  of  constant  external 
drainage  have  been  devised,  and,  w'hile  attended  in  some  cases  with 
temporary  benefit,  the  result  has  been  uniformly  fatal. 

A  case  has  been  reported  by  Rokitansky  in  which  spontaneous  rup- 
ture under  the  scalp  led  to  a  recovery.  The  idea  has  occurred  to 
Dr.  I^.  L.  McArthur,  of  Chicago,  to  drain  the  ventricular  cavities  into  the 
areolar  spaces  beneath  the  scalp  by  the  insertion  of  drainage-tubes  or 
silk  into  the  cranial  cavity  through  a  drill-opening  above  and  back  of 
the  ear.  He  attaches  the  drainage  material  to  the  pericranium, 
and  then,  securing  first-intention  healing  in  his  overlying  scalp-flap, 
allows  the  serous  accumulation  to  flow.  A  hygromatous  swell- 
ing forms  under  the  scalp  from  wliich  absorption  seems  to  be  rapid, 
and  the  head  diminishes  in  size  if  the  bony  sutures  are  not  united. 
This  operation  was  done  for  the  writer  on  the  case  shoM^n  on  page  265, 
Avith  immediate  and  lasting  improvement.  In  two  other  cases  it  also 
demonstrated  its  utility,  but  is  still  on  trial  and  not  devoid  of  danger. 
Mikulicz  and  Troje  ^  have  had  favorable  results  with  the  same  method 
independently  devised.  Others  have  established  drainage  from  the 
lumbar  spinal  spaces  into  the  peritoneum.  The  disadvantage  of  all 
surgical  procedures  is  the  liability  to  infection  and  meningitis  and  the 
peculiar  tendency  of  these  cases  to  sudden  death  from  removal  of  fluid 
or  from  the  inhibition  of  the  heat-controlling  mechanism,  which  allows 
the  temperature  to  exhaust  the  patient  in  a  few  hours. 

^  d' Astros,  "  Les  Hydrocephales, "  Paris,  1898. 
2  "  Centralblatt  f.  Chir.,"  Sept.  5,  1896. 


PAET   lY. 

DISEASES  OF  THE  SPINAL  MENINGES  AND 
SPINAL  NERVES. 


CHAPTER  I. 


SPINAL  MENINGITIS  AND  SPINAL  MENINGEAL 
HEMORRHAGE. 

Spinal  meningitis  is  an  inflammation  of  the  covering  membranes  of 
the  spinal  cord.  The  varieties  of  meningitis  ordinarily  described  have 
been  somewhat  arbitrarily  based  upon  their  anatomical  location.  The 
terms  pachymeningitis  and  leptomeningitis  are  respectively  employed,  as 
the  dura  or  the  softer  membranes  are  principally  involved,  but  a  sharp 
division  is  clinically  impossible,  and  is  not  found  post  mortem.  For 
purposes  of  description  we  may  consider  :  (1)  Pachymeningitis,  or  ex- 
ternal and  internal  inflammation  of  the  dura ;  and  (2)  leptomeningitis, 
or  inflammation  of  the  pia.  Inflammation  of  the  inner  surface  of  the 
dura,  from  contiguity,  must  involve  the  leptomeninges  more  or  less,  so 
that  the  conditions  are  usually  associated,  and  meningitis,  originally 
external,  may  finally  invade  the  pia.  Owing  to  the  very  intimate  rela- 
tion of  the  pia  and  the  fibrous  septa  of  the  cord,  association  with  mye- 
litis is  frequent.     A  mixed  form,  meningomyelitis,  is  common. 

Pachymeningitis  Externa  Spinalis. — Pachymeningitis  externa, 
or  external  dural  meningitis  of  the  spine  is  due  to  chronic  irritation  and 
inflammatory  conditions  invading  the  spinal  canal,  and  is,  therefore, 
secondary  to  other  morbid  states.  Vertebral  tuberculosis,  Pott's  disease, 
abscesses  and  new  growths  near  the  spine,  inflammation  and  purulent  col- 
lections in  the  pleurae,  mediastinum,  peritoneum,  and  pelvis,  and  sacral 
bedsores  may  be  the  source  of  the  meningeal  thickening.  This  gives  rise 
to  symptoms  mainly  by  irritation  of  the  sensory  and  motor  nerve-roots 
passing  through  the  area  of  disease.  When  the  thickening  becomes  ex- 
treme, as  occasionally  happens,  it  may  be  sufficient  to  compress  the  cord 
and  give  rise  to  pressure  symptoms  and  a  spastic  paraplegia  similar  to 
that  of  a  cross-myelitis.  The  condition  is  usually  due  more  to  the 
inflammatory  invasion  of  the  cord  than  merely  to  pressure.  There  is 
local  tenderness  over  the  spine,  shooting  or  constant  pains  in  the  dis- 
tribution of  the  irritated  nerves,  twitching  of  their  muscles,  and  hyper- 
esthesia in  their  cutaneous  areas,  which  may  go  on  to  anesthesia  and 

268 


DISEASES  OF  THE  SPINAL   MENINGES.  269 

muscular  palsy  if  the  nerves  be  sufficiently  compressed  or  inflamed  to 
cause  their  degeneration. 

Anatomically,  the  dura  is  found  hyperplastically  thickened,  with 
much  adventitious  fibrous  tissue,  and  is  frequently  covered  by  a  caseous 
or  purulent  deposit  or  involved  in  a  new  growth.  The  various  find- 
ings, of  course,  depend  upon  the  nature  of  the  primary  disease.  When 
the  thickening  is  extreme,  the  soft  membranes  are  adherent  to  the  dural 
tumescence  and  may  be  indistinguishable.  The  cord  then  shows  a  con- 
striction, and  may,  in  severe  cases  of  long  standing,  be  very  consider- 
ably reduced  in  size  at  the  place  of  disease  presenting  local  myelitis  and 
secondary  ascending  and  descending  degenerations. 

The  diagnosis  is  usually  not  difficult  if  the  primary  disease  is 
recognized.  It  may  be  confounded  with  myelitis,  with  which  it  is  often 
associated  late  in  the  case.  The  clinical  history  shows  a  preponder- 
ance of  pain,  spasm,  and  irritation,  a  chronic  course,  and  an  early 
absence  of  paralysis ;  while  in  myelitis  the  rapid  onset,  the  absence  of 
pain  aside  from  the  girdling  sensation,  and  the  promptly  developed 
paralytic  state  with  early  bladder  and  bowel  symptoms  are  distinctive. 

Owing  to  the  serious  nature  of  the  causal  conditions,  the  prognosis 
is  bad  and  treatment  is  practically  surgical.  The  pachymeningitis  externa 
associated  with  Pott's  disease  is  perhaps  the  least  grave,  as  the  proper 
orthopedic  and  surgical  management  of  such  cases  frequently  is  followed 
by  practical  recovery  even  when  the  cord  has  probably  been  notably 
compressed. 

Pachymeningitis  Interna  Spinalis. — Pachymeningitis  interna,  or 
internal  inflammation  of  the  spinal  dura,  is  described  as  (1)  hypertro- 
phic and  (2)  hemorrhagic.  In  reality,  these  forms  are  but  stages  of  one 
and  the  same  process,  the  thickening  and  hypertrophy  following  upon 
the  organization  of  the  hemorrhagic  exudate.  The  term  "  hematoma  of 
the  spinal  dura  mater"  has  been  sometimes  used.  The  condition  is  a 
rare  one,  and  usually  the  cerebral  meninges  are  also  similarly  afi'ected. 
It  is  most  commonly  found  in  general  paralysis  of  the  insane. 

The  portion  of  affected  dura  presents  on  its  inner  surface  a  very 
considerable  thickening,  which  may  be  a  layer  of  reddish-brown  exudate 
or  consist  of  laminations  of  fibrous  tissue,  the  apparent  result  of  the 
organization  of  successive  hemorrhagic  exudations.  It  may  attain 
sufficient  size  to  constrict  the  cord.  The  softer,  more  recent,  and 
reddish  or  brownish  layers  consist  of  fibrin  and  blood.  The  distribution 
is  frequently  extensive,  but  in  some  instances  it  is  confined  to  a  com- 
paratively short  vertical  extent  of  the  envelope  of  the  spinal  cord,  and 
is  then  more  frequently  situated  in  the  cervical  region.  This  circum- 
scribed cervical  form  was  first  described  by  Charcot  and  Joffroy,  who 
give  it  the  name  of  pachymeningitis  cervicalis  hypertrophica. 

Syphilis,  trauma,  alcoholism,  and  exposure  are  regarded  as  competent 
causes,  and  hence  it  occurs,  as  a  rule,  in  adult  males,  though  some 
cases  in  children  are  recorded. 

The  condition  is  essentially  chronic  and  of  slow  onset.  At  first 
irritation  of  nerve-roots  gives  rise  to  local  pain  and  hyperesthesia  over 
the  spine  and  in   the  peripheral  distribution  of  the  spinal  nerves  of 


270  DISEASES  OF  SPINAL  MENINGES  AND  SPINAL  NEE  FES. 

corresponding  origin.  This  is  followed,  months  or  years  later,  by 
gradual  loss  of  power,  atrophy,  and  anesthesia  in  the  corresponding 
parts,  and  as  compression  upon  the  cord  is  produced  spastic  symptoms 
appear  below,  with  increased  reflexes,  rigidity,  and  paraplegia,  leading 
sometimes  to  exhaustion  and  death.  Some  cases  present  stationary 
periods,  and  a  few  recoveries  are  claimed.  The  muscles  of  the  forearm 
are  not  uniformly  affected,  the  flexors  being  most  impaired.  This 
results  in  a  peculiar  deformity  that  is  striking  and  almost  characteristic. 
The  small  muscles  of  the  hand  usually  suffer  and  both  arms  are  com- 
monly affected,  though  not  usually  in  equal  degree. 

The  diagnosis  is  difficult  when  the  dural  involvement  is  of  general  dis- 
tribution and  cerebral  symptoms  are  present,  as  the  spinal  features  are 
overshadowed.  Diseases  of  the  spine,  progressive  muscular  atrophy, 
cross-myelitis,  tumor,  and  external  pachymeningitis  must  be  excluded. 
An  operation  may  be  required  to  differentiate  the  external  dural  inflam- 
mation. It  presents,  except  in  syphilitic  cases,  the  best  chance  of  favorably 
influencing  the  condition  and  preventing  destruction  of  the  cord.     In  the 


Fig.  101. — Position  of  hand,  in  pachymeningitis  cervicalis  hypertrophies. 

desperate  situation  that  is  presented  and  with  the  courage  given  by 
asepsis,  it  may  the  more  reasonably  be  resorted  to  early.  Where  syph- 
ilis is  suspected,  specific  treatment  should  be  persistently  tried. 

Acute  Spinal  Leptomeningitis. — Acute  s])inal  leptomeningitis,  or 
inflammation  of  the  pia  mater,  is  due  to  infection.  It  usually  involves 
the  inner  surface  of  the  dura,  and  commonly  extends  to  the  peripheral 
substance  of  the  cord. 

Etiology. — The  infection  of  cerebrospinal  meningitis  in  epidemics 
of  the  disease  falls  sometimes  only  on  the  cord,  and  the  infective  nature 
of  the  attack  is  obvious.  In  those  cases,  however,  that  are  attributed  to 
exposure,  insolation,  rheumatism,  and  other  occult  conditions,  the  infection 
is  less  readily  comprehended,  but  in  all  probability  is  equally  in  opera- 
tion, being  favored  by  the  physical  conditions  mentioned.  In  some  recent 
cases  the  discovery  of  the  pneumococcus  and  the  meningococcus  proves 
the  identity  of  the  infection  with  that  of  the  cerebrospinal  type,  to  which 
the  reader  is  referred.  The  association  of  cases  with  septicemia,  pyemia, 
and  other  infectious  blood-states  points  again  to  infection,  and  in  the 
lymph  and  spinal  fluid  of  these   cases  abundant  pathogenic   organisms 


DISEASES  OF  THE  SPINAL  MENINGES.  271 

have  been  observed.  In  some  instances  the  spinal  disease  is  an  exten- 
sion from  the  cerebral  meninges,  the  cervical  portion  of  the  cord  being 
usually  the  only  part  involved,  but  the  entire  dural  sheath  may  be  filled 
with  pus  from  within  the  cranium.  Traumatism  of  the  membranes  by 
vertebral  dislocations,  strains,  and  severe  concussions  may  incite  a  lepto- 
meningitis over  a  limited  area,  from  which  it  may  extend,  or  in  which 
a  virulent  infection  may  find  a  suitable  field  for  development.  Surgical 
operations  upon  the  spine,  penetrating  wounds,  sacral  bedsores,  and 
communication  with  adjoining  suppurative  foci  may  furnish  the  infection. 
Tuberculosis  is  a  common  cause,  but  the  resulting  meningitis  is  rather 
less  acute.  This  is  the  case  to  a  greater  degree  in  syphilitic  inflamma- 
tion, which  has  a  marked  tendency  also  to  remain  localized. 

Morbid  Anatomy. — The  disease  is  usually  of  wide  extent,  the 
infection  traveling  rapidly  through  the  arachnoid  spaces,  and  finding  in 
the  spinal  fluid  an  excellent  medium  for  its  propagation  and  extension. 
Congestion  of  the  pia,  of  the  adjoining  inner  surfaces  of  the  dura,  and 
of  the  cord,  marked  by  increased  vascularization  and  an  increase  of 
spinal  fluid,  passes  into  inflammation,  with  dulness  of  the  membranes, 
opacity,  thickening,  and  an  exudate,  varying  in  color  from  opalescent  to 
puriform,  and  of  corresponding  consistency.  The  microscope  shows  the 
diapedic  elements  of  inflammation  and  often  numerous  bacteria,  includ- 
ing at  times  the  pneumococcus  of  Friedlander.  Tubercles  here  corre- 
spond to  their  histological  and  bacterial  characters  on  other  serous 
surfaces.  For  a  time  the  somewhat  resistant  pial  covering  of  the  cord 
and  nerve-roots  protects  these  structures,  and  especially  is  this  true  in 
the  purulent  form  of  the  disease.  Usually  the  periphery  of  the  cord 
and  the  roots  show  the  inflammatory  invasion,  with  corresponding 
changes  in  the  nerve-fibrils,  neuroglial  framework,  and  vessels.  In 
cases  reaching  a  convalescent  or  chronic  stage,  adhesions  form  betv^^een 
the  cord  and  the  dura,  obliterating  the  arachnoid  space  over  more  or  less 
extensive  areas,  distorting  the  nerve-roots,  and  sometimes  changing  the 
outlines  of  the  cord  itself.  If  cord-softening  has  taken  place  as  a  result 
of  the  meningomyelitis,  degenerations  of  its  conduction  tracts  and  local- 
ized destruction  of  its  gray  matter  are  found.  Large  quantities  of 
spinal  fluid  usually  mark  these  late  cases,  causing,  with  the  irregular 
adhesions,  a  sacculated  condition  of  the  dura. 

Symptoms. — The  abrupt  onset  of  the  disease  may  be  preceded  by 
a  day  or  two  of  malaise  and  slight  anorexia,  but  sometimes  no  invasion 
period  is  present.  A  sharp  chill  is  followed  or  attended  by  great  pain 
in  the  back  and  darting  pains  around  the  body  or  down  the  limbs.  In 
children  vomiting  is  a  common  symptom,  and  convulsions  may  be  pres- 
ent. Tenderness  is  at  once  developed  over  the  spine.  It  is  easily 
detected,  when  not  prominent,  by  the  use  of  a  sponge  dipped  in  hot 
water  or  by  percussion.  Spasm  and  rigidity  of  the  muscles  appear, 
causing  stiffness  of  the  neck  and  back,  sometimes  notable  retraction  of 
the  head  and  vigorous  opisthotonos.  Fixation  of  the  limbs  upon  the 
body  is  more  or  less  marked,  with  a  tendency  to  flexed  attitudes. 
Retraction  of  the  belly  results  from  implication  of  the  abdominal  mus- 
cles.    Sometimes  difliculty  of  breathing  is  occasioned  by  involvement 


272  DISEASES  OF  SPINAL  JIEXIXGES  AXD  SPIXAL  XERVES. 

of  the  chest-muscles.  Dyspnea,  Cheyne-Stokes  respiration,  and  cardiac 
symptoms  follow  medullary  implication.  The  cramps  in  the  muscles 
are  painful,  and  yet  tenderness  and  hyperesthesia  in  the  limbs  prevent 
manipulations  and  passive  movements.  The  rectum  and  Ijladder  are 
the  seat  of  similar  spasms,  which  may  cause  constipation  and  retention 
of  urine,  with  frequent  annoying  and  ineffectual  expulsive  contractions 
of  these  viscera. 

Pulse  and  temperature  are  tickle,  sometimes  being  suljnormal,  some- 
times increased,  and  more  often  divergent ;  for  instance,  a  subnormal 
temperature  with  an  accelerated  pulse.  The  lack  of  uniformity  in  their 
range  is  especially  valuable  in  diagnosis,  even  when  the  cerebrum  is 
apparently  not  involved.  A  temperature  of  103°  F,  is  not  uncommrm. 
Vasomotor  paralysis  is  usually  shown  by  the  vivid,  persistent,  but 
slowlv  developed  line  which  follows  every  stroke  of  the  finger-nail 
upon  the  skin,  and  from  the  same  catise  the  limbs  may  be  congested 
and  even  slightly  edematous.  At  first,  for  a  day  or  two,  rejiexes  are 
inclined  to  be  increased  and  later  may  be  wanting. 

Cases  which  outlast  the  acute  symptoms  develop  paralysis,  anes- 
thesia, atrophy,  and  contractures  in  j)roportion  as  the  cord  and  nerve- 
roots  are  affected.  Paraplegia  may  result,  presenting  the  features  of  a 
cross-myelitis,  with  bladder-paresis,  bedsores,  increased  reflexes,  and 
spasticity.  Symptoms  vary  with  the  location  of  the  disease,  but  its 
tendency  to  involve  the  entire  spinal  apparatus  is  marked,  and  indica- 
tions of  its  effect  upon  all  spinal  segments  are  to  some  degree  present 
in  a  majority  of  instances.  Some  regions  situated  in  the  focus  of  the 
inflammatory  action  show  early  and  emphatic  involvement;  those  at  a 
distance  may  be  disturbed  very  little.  Yet  in  some  purulent  cases, 
where  the  dural  sheath  is  greatly  distended  through  its  entire  length 
with  the  large  accumulation,  the  pia  protects  the  cord  and  nerve-roots 
from  infection,  so  that  pressure  symptoms  alone  may  be  present. 

Course. — Some  cases  terminate  fatally  within  a  day  or  two ;  others 
last  a  fortnight,  and  may  then  end  fatally  or  recover.  The  nature  and 
virulence  of  the  infection  are  determining  factors,  as  is  the  location  of 
the  disease.  Extension  upward  or  early  involvement  of  the  high  levels 
of  the  cord  tend  to  an  early  fatal  issue.  Complete  recovery  is  rare  and 
the  conditions  resulting  from  secondary  myelitis  are  of  long  duration 
and  usually  last  the  life-time.  The  tubercular  and  syphilitic  varieties, 
as  already  indicated,  run  their  coiu^se  less  rapidly,  and  the  latter  is 
capable  of  material  modification  by  treatment.  Even  rare  tubercular 
cases  may  get  well. 

Diag-nosis. — The  diagnosis  depends  upon  the  rapid  onset,  tlie  pain 
in  the  back,  the  radiating  pains,  the  rigidity,  the  increase  of  pain  on 
voluntary  movement,  the  hyperesthesia,  and  the  fickle  temperature  and 
pulse.  From  myelitis  it  is  distinguished  by  the  paralysis  and  lack  of 
pain  which  characterize  the  cord-lesion,  ])ut  the  frequent  association  of 
the  two  is  to  be  kept  in  mind.  Hemorrhage  into  the  subdural  space, 
owing  to  the  irritation  of  the  nerve-roots,  presents  very  similar 
symptoms,  but  is  extremely  rapid  in  onset,  usually  following  traumatism 
or  a  strain,  and  develops  meningitis  in  a  short  time  thereafter.      Hem- 


DISEASES  OF   THE  SPINAL   MENINGES.  273 

orrhage  into  the  spinal  cord  gives  instantaneous  symptoms,  immediate 
paralysis,  and  may  be  })ractically  devoid  of  pain.  The  rigid  form  of 
tetany  may  present  a  very  close  counterfeit,  but  its  long  duration, 
remissions,  and  amenability  to  spinal  sedatives,  the  absence  of  spinal 
tenderness  and  sh<joting  pains,  the  possible  history  of  previous  attacks, 
and  the  usual  irritaljility  from  pressure  upon  the  nerve-trunks  and 
arteries  should  ditt'erentiate  it.  Tetanus  may  be  mistaken  for  spinal 
meningitis.  The  early  trismus,  the  excessive  hy])eresthesia,  the  fever 
of  onset,  the  paroxysms  of  spasm,  and  the  frequent  liistory  of  traumatism 
point  the  way  to  diagnosis.  Muscular  rheumatism  and  strain  present  a 
very  superficial  resemblance. 

Prog-nosis. — The  outlook  as  to  life  is  always  serious  and  is  grave 
in  proportion  to  the  acuteness  of  the  onset,  to  the  virulence  of  the  in- 
fection, to  the  implication  of  the  upper  portion  of  the  cord,  and  to  the 
height  of  temperature.  The  estimate  is  also  to  be  guided  by  the 
previous  condition  of  health  and  the  age  of  the  patient,  children  and  the 
aged  quickly  yielding  to  the  disease.  Traumatic  and  surgical  infection 
is  less  serious  than  auto-infection.  The  possibility  of  the  removal  of 
sources  of  infection  is  of  some  importance  as  to  ultimate  results,  pro- 
vided the  patient  survives  the  acute  stage.  The  late  results,  due,  for  the 
most  part,  to  permanent  changes  in  the  cord,  are  usually  beyond  the 
liope  of  marked  improvement. 

Treatment. — Complete  and  absolute  quiet  is  to  be  insisted  upon. 
The  patient  should  be  kept  upon  the  side  or  face,  if  it  is  possible  to  do 
so  without  increasing  the  cramps.  The  partial  knee-elbow  posture 
over  a  mound  of  firm  pillows  will  often  be  found  very  comfortable,  and 
at  the  same  time  will  afford  the  best  opportunity  for  local  applications. 
These,  at  first,  should  be  strongly  counterirritant,  as  the  thermocautery, 
iDlisters,  or  detergents  like  leeches,  vigorous  dry  cupping,  or  wet  cups  in 
robust  or  plethoric  individuals.  Should  myelitis  be  associated,  less 
active  measures  are  indicated,  and  the  skin  must  not  be  broken  or 
highly  irritated,  owing  to  the  tendency  to  bedsores.  A  hot  bath  and 
pack  at  the  onset  with  active  catharsis  have  seemed  to  do  good.  Seda- 
tives, especially  spinal  sedatives,  are  frequently  required  to  control  the 
spasms  and  anodynes  to  relieve  the  pains.  A  thorough  course  of 
mercurial  inunctions  over  the  spine  has  strong  advocates,  the  quantity 
used  being  sufficient  to  produce  slight  ptyalism.  Owing  to  the  reflex 
irritability,  these  rubbings  must  often  be  impossible,  and  the  therapeutic 
value  of  mercury  in  the  acute  stage  of  non-luetic  cases  is  open  to  question. 
Quincke's  lumbar  puncture  has  here- the  same  indications  as  in  the 
cerebrospinal  form.  lodid  of  potassium  and  ergot  are  also  at  this 
time  of  little  or  no  value.  The  ice-bag  to  the  spine  is  one  of  the  most 
serviceable  measures,  but  is  rarely  tolerated  long  by  the  patient,  and  its 
intermittent  application  is  useless.  It  should  always  be  tried.  As  the 
-active  stage  subsides,  light  cauterizations  with  the  Paquelin  apparatus, 
mild  sinapisms  applied  for  six  or  eight  hours,  and  the  hot-spray  douche 
seem  to  assist  the  reparative  eiforts  of  nature.  Cerebral  symptoms 
usually  mean  the  implication  of  the  brain-coverings,  the  spinal  features 
become  of  secondary  importance,  and  the  treatment  is  that  of  cerebro- 
18 


274  DISEASES  OF  SPINAL  MENINGES  AND  SPINAL  NERVES. 

spinal  meningitis.  The  paralysis,  contractures,  and  other  late  results 
of  the  myelitis  are  to  be  managed  in  accordance  with  the  rules  of 
practice  in  that  disease. 

Chronic  Spinal  Leptomeningitis. — The  chronic  form  of  inflam- 
mation of  the  soft  spinal  membranes  is  usually  the  sequential  stage  of  an 
acute  attack,  but  may  follow  alcoholism,  syphilis,  or  tuberculosis.  Its 
existence  as  a  primary  affection  is  open  to  some  doubt,  but  a  very  slowly 
developed  leptomeningitis  may  follow  concussion,  though  it  is  impossible 
in  such  a  case  to  exclude  immediate  slight  histological  injuries  of  which 
the  later  inflammation  is  a  natural  development.  The  formerly  much 
used  term  "  chronic  meningitis,"  which  was  applied  to  every  group  of 
obscure  subjective  symptoms,  however  remotely  referable  to  the  spine, 
needs  no  mention. 

The  symptoms  are  practically  those  of  the  acute  form  much  reduced 
in  intensity,  and  are  dependent  upon  similar  causes.  Pain  in  the  back 
predominates,  and  spasm  is  insignificant  or  absent.  The  radiating  neu- 
ralgic pains  are  especially  pronounced,  and  paresthesise  are  prominent. 
Their  distribution  depends  upon  the  nerve-roots  involved  and  the  loca- 
tion of  the  inflammation,  which  is  much  more  circumscribed  than  in  the 
acute  form.  The  kite  manifestations  are  those  due  to  neuritis  originat- 
ing in  the  roots,  and  myelitic  symptoms  are  comparatively  infrequent. 

The  anatomy  of  the  disease  is  very  little  known,  as  opportunity  for 
post-mortem  examination  rarely  occurs,  but  more  or  less  extensive  fibrous 
thickening,  or  adhesions  between  the  pia  and  dura  which  constrict  the 
nerve-roots,  may  be  found,  and  may  girdle  the  cord.  Degeneration  of 
the  spinal  nerves  traversing  the  lesion  is  not  rare,  and  this  accounts  for 
the  herpetic  and  other  cutaneous  symptoms  which  are  occasionally  noted. 

The  prognosis  will  be  guided  mainly  by  the  effect  of  treatment,  but 
a  complete  recovery  is  very  rare.  Each  case  must  be  carefully  estimated 
by  itself. 

The  treatment  in  syphilitic  cases  consists  in  the  heroic  management 
of  that  disease,  and  iodids  and  mercury  in  small  doses  are  also  the  most 
efficient  drugs  in  non-luetic  cases.  General  measures  are  of  service,  and 
persistent  counterirritation  over  the  sj^ine,  preferably  by  Paquelin's 
cautery,  is  the  most  valuable  local  measure.  Sometimes  rest  in  bed 
and  the  ice-bag  to  the  spine  are  of  distinct  value.  Sedatives  and 
analgesics  are  often  required. 

Spinal  Meningeal  Hemorrhage. — Spinal  meningeal  hemorrhage 
is  either  ext-adura/,  in  the  vertebral  canal,  or  subdural,  within  the  dural 
sheath.  It  is  frequently  associated  with  intracranial  hemorrhage  and 
with  hemorrhage  into  the  substance  of  the  cord,  but  also  occurs  inde- 
pendently. 

Etiolog-y. — Meningeal  hemorrhage  occurs  frequently  at  birth  in 
protracted  and  difficult  labors,  and  is  then  almost  invariably  associated 
with  extensive  hemorrhage  within  the  skull.  It  has  been  considered 
under  the  cerebral  palsies  of  childhood.  Spontaneous  hemorrhage  is 
very  rare,  but  occurs  in  adult  life  at  all  ages.  Disease  of  the  meningeal 
vessels  is  sometimes  the  immediate  cause,  but  in  the  great  majority  of 
cases  it  is  induced  by  traumatism.     It  may  be  caused  by  direct  blows 


DISEASES  OF  THE  SPINAL  MENINGES.  275 

or  falls  upon  the  back,  shock  communicated  through  the  lower  limbs, 
vertebral  fractures  and  dislocations,  penetrating  wounds  and  even  by 
severe  muscular  spasm,  as  in  tetanus,  convulsions,  and  violent  chorea. 
No  doubt  syphilis,  arteriosclerosis,  purpura,  scurvy,  and  other  hemor- 
rhagic states  favor  it.  The  blood  sometimes  comes  from  a  thoracic  aneur- 
ysra  which  has  eroded  the  vertebrae  and  ruptured  into  the  spinal  canal  or 
dura,  or  from  one  situated  on  the  vertebral  or  basilar  arteries.  Hem- 
orrhage into  the  cerebral  meninges  may  find  its  way  below  the  foramen 
maa^num,  and  in  the  same  way  a  spinal  hemorrhage  may  invade  the 
cranium. 

Morbid  Anatomy. — In  extradural  cases  the  clot  usually  originates 
from  the  rich  plexuses  of  veins  that  line  the  vertebral  canal.  It  may 
be  of  considerable  size  and  extend  through  the  intervertebral  foramina. 
The  most  common  location  is  in  the  cervical  region.  The  dura  is 
stained  and  infiltrated,  and  the  cord  may  exceptionally  be  compressed. 
Effusions  of  blood  ivithhi  the  dura  vary  much  in  size.  The  blood  usu- 
ally comes  from  the  pial  vessels,  and  consequently,  as  a  rule,  involves 
the  cord.  Complete  flooding  of  the  dural  sheath  is  almost  always  due 
to  intracranial  hemorrhage  or  rupture  of  an  aneurysm.  A  small  hemor- 
rhage tends  to  remain  localized  and  to  surround  the  cord  at  the  original 
point.  It  discolors  and  compresses  the  cord  and  after  a  few  days  pro- 
duces inflammatory  changes  in  the  meninges.  In  the  same  way  an 
annular  iiiyelitis  may  be  induced. 

Syraptoms. — The  symptoms  are  practically  the  same  in  both  extra- 
and  subdural  hemorrhage.  The  onset  is  ordinarily  abrupt  and  the  early 
symptoms  depend  upon  irritation  of  the  meninges  and  nerve-roots. 
There  is  great  pain  in  the  back,  which  often  radiates  along  the  impli- 
cated nerves,  girdling  the  body  or  running  down  the  extremities.  Tin- 
gling and  formication  are  complained  of,  and  paralytic  symptoms  below 
the  level  of  the  lesion,  loss  of  power,  and  diminished  sensation  are  induced. 
Bladder  and  bowel  symptoms  shortlv  appear.  There  is  ordinarily  some 
spinal  rigidity,  which  may  develop  into  opisthotonos,  and  convulsions  are 
not  infrequent.  Symptoms  are  gradually  developed  unless  the  hemorrhage 
is  due  to  severe  traumatism  or  to  flooding  of  the  vertebral  canal  by  the 
rupture  of  an  aneurysm.  In  crushing  injuries,  spinal  fractures,  and 
dislocations  the  cord  is  almost  invariably  injured,  and  hemorrhage,  if 
present,  adds  very  little  to  the  symptoms.  From  the  onset  to  the  full 
development  of  the  paralytic  features  from  one  or  two  to  forty-eight 
hours,  or  even  more,  may  be  required.  The  symptoms,  therefore, 
greatly  resemble  those  of  spinal  meningitis,  which  usually  is  added 
after  a  few  days,  and  its  invasion  is  often  marked  by  a  distinct  aggrava- 
tion of  all  the  symptoms. 

Cerebral  symptoms  are  only  present  when  the  cranial  contents  are 
simultaneously  affected.  Death  is  likely  to  occur  early  when  the  symp- 
toms have  reached  their  height,  or  during  the  secondary  meningitis. 

Diagnosis. — In  cases  of  insidious  onset  without  definite  symptoms, 
the  diagnosis  at  best  can  be  but  conjectural.  When  hemorrhage  follows 
traumatism,  the  distinguishing  trait  is  a  gradual  development  of  the 
symptoms  within  a  few  hours.      Injuries  that  affect  the  cord-substance 


276  DISEASES  OF  SPINAL  MENINGES  AND  SPINAL  NERVES. 

produce  instantaneous  loss  of  function,  but  a  meningeal  hemorrhage 
may  be,  and  often  is,  associated  with  hemorrhage  into  the  cord.  Jacobi 
has  also  obtained  blood  by  spinal  puncture  in  two  cases  of  injury  of  the 
spine.  1  From  meningitis  the  chief  distinction  is  the  much  more  rapid 
development  in  hemorrhage  and  the  history  of  a  competent  cause.  The 
localizing  diagnosis  is  taken  up  in  subsequent  chapters,  to  which  the 
reader  is  now  referred. 

Prognosis. — The  outlook  is  always  most  serious.  As  the  paralytic 
features  develop,  there  is  a  likelihood  of  death  from  interference  with 
respiration  by  paralysis  of  the  chest-muscles.  The  intense  pain  and 
suffering  also  serve  to  exhaust  the  patient.  The  first  danger  being 
passed,  secondary  inflammation  is  likely  to  terminate  the  case  fatally. 
Hemorrhage  in  the  cervical  region  is,  of  course,  more  ominous  than 
when  situated  lower  down.  If  the  patient  survives  the  first  fortnight, 
improvement  may  be  confidently  expected,  and  this  may  practically  be 
complete,  though  some  disability  remains,  as  a  rule,  and  it  may  be  of  an 
extreme  degree. 

Treatment. — At  first  the  most  complete  rest  on  the  face  or  side  with 
the  spine  elevated  should  be  secured.  An  ice-bag  to  the  back  is  a  valu- 
able measure  if  persistently  and  thoroughly  used.  Venesection  to  lower 
the  blood-pressure  has  been  used,  but  will  not  find  many  brave  enough 
to  employ  it.  Local  wet  cu2)s  with  free  flow  of  blood  have  also  been 
employed,  but  are  of  doubtful  value.  Remedies  that  increase  the  coagu- 
lability of  the  blood  may  be  exhibited,  but  ordinarily  the  flow  of  blood 
is  of  but  a  few  moments'  duration,  and  no  time  is  given  for  their  action. 
If  the  diagnosis  is  fairly  certain,  the  spinal  canal  should  be  aseptically 
opened  and  the  dural  sheath  also  incised.  The  operation  as  now  done 
adds  nothing  to  the  gravity  of  the  case,  and  has  enabled  the  surgeon  to 
remove  clots  with  the  best  results.  The  secondary  meningitis  and  the 
sequential  palsies  are  to  be  treated  on  tlieir  own  indications. 


CHAPTER    11. 

INJURIES  AND  DISEASES  OF  SPINAL  NERVES. 

The  spinal  nerves,  unlike  the  cranial  group,  are  both  motor  and 
sensory.  In  addition  they  contain  the  vasomotor  supply,  and  through 
them  is  exerted  the  trophic  influence  of  the  spinal  centers  over  the 
peripheral  apparatus.  Their  injury  or  disease  is,  therefore,  marked  by 
perversion  or  abolition  of  these  functions,  and  gives  rise  to  groups  of 
symptoms  anatomically  coextensive  with  the  distribution  of  the  particu- 
lar nerve  or  nerves  involved.  We  should  bear  in  mind  that  the  fibers 
making  up  a  nerve-trunk  are  cellular  elements, — prolongations  from 
cell-bodies,  of  which  they  form  an  integral  and  functionally  essential 
part.  When  we  injure  a  motor  fiber  in  a  nerve-trunk,  we  injure  a 
motor  cell.  In  other  words,  we  injure  the  lower  motor  neuron.  We  will 
first  consider  nerve  injuries  and  diseases  in  a  general  way,  and  then  the 
particular  conditions  which  pertain  to  such  states  in  special  nerves.. 
1  "Amer.  Jour.  Med.  Sciences,"  Oct.,  1900. 


INJURIES  AND  DISEASES  OF  SPINAL  NERVES. 


277 


Division  of  Nerves. — Spinal  nerves  are  frequently  divided  by 
incised  and  bullet  Avounds,  s(jinetimes  by  crushing  accidents,  by  simple 
and  compound  fractures,  and  rarely  by  dislocations.  Causes  acting 
more  slowly  may  end  in  the  destruction  of  a  nerve,  but  a  neuritis  or 
degeneration  is  usually,  if  not  always,  first  induced.  After  a  nerve  is 
divided  the  peripheral  portion  degenerates,  and  the  process  is  called 
seconda ) -y  degenera t ion . 

The  immediate  symptoms  are  loss  of  motion,  sensation,  and  muscular 
reflexes  in  the  distribution  of  the  nerve.  Shortly  afterward,  within 
forty-eight  hours,  the  muscles 
supplied  by  the  injured  nerve 
lose  their  tonicity  and  then  pro- 
gressively waste.  Vasomotor  par- 
alysis appears  and  trophic  dis- 
turbances in  the  cutaneous  area 
of  distribution  are  marked  by  a 
thin,  shiny  skin,  with  atrophic 
hairs,  nails,  and  other  epithelial 
structures.  There  is  also  a  low- 
ered vital  resistance  to  infection, 
and  healing  processes  are  slow 
and  faulty.  Even  the  joints  are 
sometimes  affected,  and  bony 
growth  in  the  young  is  retarded. 
Electrical  stimulation  through 
the  nerve  fails  completely.  The 
muscles  lose  their  responsiveness 
to  faradism,  and  the  increased 
galvanic  irritability  which  at  first 
appears  gradually  subsides  and  is 
finally  lost.  The  electrical  changes 
constituting  the  reaction  of  degen- 
eration are  more  fully  described  in 
Part  I,  page  45.  In  the  extremi- 
ties the  unapposed  antagonist  mus- 
cles then  draw  the  joints  into 
fixed,  rigid  positions.  Muscular 
contractures  develop  and  still  fur- 
ther tend  to  deform  the  part. 

The  histological  changes  that  take  place  in  the  distal  portions  of  the 
divided  nerve  are  as  follows  :  The  nuclei  of  the  internodal  nerve-cells 
swell,  and  their  protoplasm  becomes  increased  in  quantity,  but  changed 
in  character,  as  it  no  longer  stains  so  actively  as  in  health.  The  nuclei 
also  become  segmented,  and  with  the  increase  in  protoplasm  encroach 
upon  the  myelin  and  displace  it.  The  nerve-fiber  then  shows  an 
irregular  beading  of  the  myelin,  and  at  the  points  of  greatest  constric- 
tion the  myelin  finally  separates  transversely,  and  the  axis-cylinder 
is  divided  at  the  same  time  and  in  the  same  way.  This  process  takes 
place  uniformly  throughout  the  length  of  the  divided  nerve  below  the 


Fig.  102. — Nerve  tubules  in  peripheral  portion  of 
a  divided  nerve — A,  two  day.s  after  section  ;  B,  four 
days  after  section;  C,  eight  days  after  section.  1, 
Sheath  of  Schwann;  2,  myelin  ;  3,  nuclei;  i,  proto- 
plasm (Ranvier). 


278  DISEASES  OF  SPINAL  MENINGES  AND  SPINAL  NERVES. 

lesion.  The  segmented  myelin  becomes  more  and  more  aqueous,  escapes 
in  part  through  its  sheath,  and  is  absorbed.  The  nuclei  cease  prolifera- 
tion, and  the  nerve-fiber  is  left  a  mere  connective-tissue  filament,  except 
at  irregular  intervals, where  remaining  globules  of  myelin  may  distend  it. 

The  segmentation  of  the  myelin  in  man  reaches  the  point  of  complete 
division  and  consequent  rupture  of  the  axis-cylinder  at  about  the  end 
of  the  third  day  after  nerve-division.  At  this  time  electrical  conduc- 
tion or  excitability  in  the  nerve  is  also  lost  and  muscular  tonus  is 
destroyed.  The  entire  process  of  degeneration  after  nerve-division  may 
be  completed  within  three  weeks. 

Above  the  point  of  division  the  central  dumj)  degenerates  for  about 
a  third  of  an  inch  only,  but  there  is  reason  to  believe  that  the  cell-body 
is  also  disturbed  (Marinesco). 

The  muscles  supplied  by  a  divided  motor  nerve  are  deprived  of  the 
trophic  influence  of  the  spinal  center  as  soon  as  division  takes  place^  and 
the  axis-cylinder  below  the  lesion  is  equally  deprived  of  the  trophic 
support  of  the  cell-body.  The  sarcode  elements  waste.  The  cross  stria- 
tions  become  less  well  marked  and  are  closer  together  ;  the  muscle-fibers 
become  narrowed,  cloudy,  granular,  and  sometimes  fatty.  There  is  pro- 
liferation of  the  connective-tissue  elements  of  the  muscles,  which  further 
strangulates  the  muscle-cells,  and  eventually  a  condition  of  fibrosis  or 
cirrhosis  is  developed.  Tiiis  has  a  natural  tendency  to  contract  and 
shorten,  and  explains  the  fibrous,  tense,  cord-like  structures  and  deform- 
ities found  in  such  cases  of  long  standing. 

The  electrical  changes  that  occur  in  the  muscle  are  also  described  in 
Part  I,  page  46.  Faradic  muscular  contractions  are  lost  within  a  few 
-days,  but  at  first,  for  about  a  week,  the  muscles  react  to  galvanism  even 
more  freely  than  in  health ;  then  the  galvanic  excitability  of  the  muscle 
is  diminished  and  disappears. 

When  the  ends  of  a  divided  nerve  are  brought  together  uuder  proper 
conditions  for  healing,  regeneration  may  occur  in  the  peripheral  portion 
even  when  degeneration  is  complete  and  of  long  standing.  Bowlby  has 
noted  one  case  of  regeneration  after  fourteen  years'  division.  In  nerves 
freshly  divided  and  at  once  united,  the  functions  of  the  nerve  are 
restored  in  a  few  days  or  weeks.  After  degeneration  has  been  estab- 
lished regeneration  is  a  slow  process,  requiring  from  two  months  to 
several  years,  depending  upon  the  condition  of  the  peripheral  segment  and 
the  surgical  features  of  the  given  case.  According  to  Tizzoni,  Kennedy, 
Bethe,  Ballance,  and  Stewart, ^  regeneration  in  a  divided  nerve  is  depen- 
dent upon  proliferation  of  the  neurilemma  cells.  At  the  end  of  three  weeks 
spider-like  neuroblasts  are  seen  sending  out  beaded  axis-cylinder  processes 
in  both  directions  from  opposite  poles,  which  at  the  end  of  the  fourth  week 
may  overlap  and  anastomose.  A  new  medullary  sheath  appears  about  the 
eleventh  week.  Neither  axis-cylinder  nor  medullary  sheath  attains  full 
maturity  unless  the  distal  segment  is  joined  to  the  proximal  nerve-stump. 
Nonmyelinated  nerves,  as,  for  instance,  cerebral  conduction  tracts,  do  not 
regenerate,  lacking  the  necessary  cellular  elements  required  for  that  pro- 
cess. The  muscles  in  turn  regenerate,  and  slight  volitional  motion  returns 
before  electrical  responses  can  be  obtained  with  the  usual  tests.      These 

iMacniillan&  Co.,  1901. 


INJURIES  AND  DISEASES  OF  SPINAL  NERVES.  279 

appear,  as  a  rule,  shortly  after  voluntary  power  is  manifested,  and  while  it 
is  still  very  slio;ht.  Sensory  conduction  is  usually  restored  before  mus- 
cular action.      The  muscle  reflexes  are  the  last  to  reappear. 

It  Jieed  scarcely  be  added  that  the  only  treatment  for  a  divided  nerve 
is  surgical  suture.  Whenever  tlie  distal  extremity  can  be  aseptically 
united  to  the  central  end,  and  in  proportion  as  it  is  done  promptly  after 
the  division,  the  prospects  for  a  return  of  function  are  good.  In  cases 
marked  by  degeneration,  electrical  stimulation  should  be  early  and  per- 
sistently employed,  even  if  no  motor  response  is  obtained. 

Neuritis. — Peripheral  nerves  are  subject  to  inflammatory  action  of 
every  grade  of  severity,  arising  from  an  extraordinary  number  of  causes. 
Many  toxic  conditions  and  cachexise  cause  widely  distributed  and 
usually  bilateral  symptoms,  due  to  degenerative  states  in  the  peri- 
pheral nervous  apparatus,  producing  a  so-called  multiple  neuritis,  the 
consideration  of  which  is  reserved  for  a  separate  chapter.  We  have 
here  to  deal  with  a  nerve  inflammation  or  degeneration  arising  from 
local  causes.  The  particular  cause,  however,  may  be  the  topical  feature 
of  a  systemic  disease,  as  when  a  nerve  is  involved  in  a  syphilitic  tumor 
or  a  gouty,  nodular  thickening.  Consequently  the  lesion  in  question  is 
confined  to  one  nerve  or  to  several  that  are  anatomically  related. 

Etiology. — Slight  compression  or  contusion  may  cause  temporary  or 
persisting  disturbance  in  the  function  of  nerve-trunks, — a  fact  made 
familiar  by  knocking  or  pressing  upon  the  ulnar  at  the  elbow  or  by 
pressing  on  the  sciatic  in  sitting.  If  the  compression  or  contusion  is  of 
sufficient  severity,  the  nerve  may  be  an  indefinite  time  in  recovering,  and 
long-continued  pressure  or  extreme  contusion  may,  like  actual  division, 
induce  a  complete  degeneration.  Dislocations,  fractures,  the  formation  of 
callus,  violent  muscular  contractions,  strains,  cramped  positions  or  con- 
tinued pressure  in  sleep,  coma,  surgical  anesthesia  and  extreme  prostration, 
pressure  from  the  continued  use  of  surgical  appliances,  crutches,  trusses, 
and  constricting  shoes  or  garments  are  among  such  causes.  A  nerve 
may  be  icounded  or  infected  in  surgical  and  accidental  ways,  and  by  the 
hypodermatic  needle.  It  may  be  invaded  by  extension  from  a  neighboring 
inflammation,  as  in  arthritis,  pleurisy,  meningitis,  bedsores,  abscesses, 
or  any  other  inflammatory  focus.  Exposure  to  cold  is  especially  active, 
as  in  the  facial  nerve  and  others  that  are  superficial  or  contained  in 
rigid  canals  and  passages.  New  growths,  like  cancer  and  gumma,  and 
infiltrations  in  leukocythemia,  cancer,  leprosy,  and  syphilis  may  cause 
a  neuritis. 

There  are  also  a  number  of  predisposing  causes,  some  of  which  are 
active  in  the  etiology  of  multiple  neuritis.  Here  may  be  enumerated 
gout,  rheumatism,  diabetes,  exposure  to  cold,  alcohol,  lead,  and  cachexise 
generally.  In  such  conditions  an  exciting  cause  acts  more  readily  and 
repair  takes  place  more  tardily. 

Morbid  Anatomy. — The  anatomical  changes  in  a  neuritis  vary 
according  to  the  intensity  of  the  process  and  the  particular  elements 
in  the  nerve-trunk  that  are  most  affected.  When  the  nerve-fibers  are 
mainly  involved,  we  speak  of  a  parenchymatous  neuritis.  This  form  is 
rarely  secondary  to  a  local  injury,  but  sometimes  so  arises.  It  is  the 
common  form  in  the  multiple  neuritis  of  systemic  states.     When  the 


280         DISEASES  OF  SPINAL  MENINGES  AND  SPINAL  NERVES. 

fibrous  structure  of  the  nerve-trunk  is  most  affected,  the  neuritis  is 
called  adventitious.  In  the  case  of  inflammatory  extension  from  adjoin- 
ing structures  the  sheath  or  surface  of  the  nerve  is  usually  first  involved, 
and  the  condition  is  then  distinguished  as  a  perineuritis. 

An  acutely  inflamed  nerve  looks  reddened  and  presents  increased 
vascularity.  There  is  sometimes  distinct  edema,  or  a  jelly-like  infiltra- 
tion of  the  sheath  and  adventitia  may  be  seen.  This  is  ordinarily  con- 
fined to  a  limited  extent  of  the  nerve,  or  may  be  seen  at  numerous 
points.  It  is  particularly  likely  to  be  present  where  the  nerve  is  super- 
ficially placed  over  firm  structures,  as  where  a  nerve  passes  over  bony 
prominences  or  is  tightly  enveloped  in  fascial  or  bony  tissues.  From 
pressure  or  irritation  thus  arising,  changes  of  corresj)onding  degree  take 
place  in  the  nerve-fibrils.  When  the  neuritis  or  even  the  contusion  is 
sufficiently  severe  to  disrupt  the  myelin  for  a  few  hours,  we  have  a 
descending  degeneration  below  the  lesion,  which  then  presents  the  morbid 
appearances  described  in  nerves  after  complete  division.  In  the  case 
of  neuritis,  however,  it  is  common  for  some  fibers  to  escape,  and  to  appear 
practically  normal  in  the  cross-section  of  the  degenerated  nerve. 

As  a  rule,  the  inflammatory  and  degenerative  process  is  confined  to 
the  injured  portion  of  the  nerve  and  the  parts  beyond,  but  occasionally, 
and  then  usually  in  the  case  of  infected  wounds,  the  neuritis  extends  up- 
ward, and  if  it  reaches  the  plexus  of  origin  may  there  involve  other 
nerve-trunks  related  to  it.  This  ascending  form  is  sometimes  called 
neuritis  migrans.  In  cases  of  long  standing  the  adventitia  is  increased 
and  a  fibrous  thickening  of  the  nerve  may  result,  which  persists  even 
after  restitution  of  function  has  taken  place.  In  unrecovered  cases  the 
degenerated  nerve  may  be  reduced  to  a  mere  fibrous  filament. 

Infiltration  in  syphilis  and  cancer  is  identical  with  these  processes 
elsewhere,  and  may  cause  distinct  tumors  in  or  on  the  nerves.  In 
leukocythemia  and  leprosy  there  is  merely  an  infiltration,  which  in 
the  latter  may  contain  the  characteristic  bacilli.  Perhaps  the  same 
may  be  true  in  neuritis  arising  from  tubercular  ulcerative  lesions. 

Symptoms. — The  symptoms  of  neuritis  vary  greatly.  They  may  be 
mainly  those  of  irritation  or  those  of  destruction  of  the  conducting  func- 
tions of  the  nerve-fibrils.  Ordinarily  both  are  present.  Local  condi- 
tions at  the  point  of  original  nerve  injury,  such  as  swelling,  contusion,  or 
laceration,  may  be  added.  The  onset  is  ordinarily  abrupt,  in  the  case  of 
traumatism  instantaneous.  When  the  nerve  is  insidiously  invaded  the 
symptoms  develoj)  with  corresponding  slowness.  The  sensory  disturb- 
ances are  usually  the  most  prominent  at  first.  All  varieties  of  paresthe- 
sia are  complained  of:  Formication,  numbness,  tingling,  burning,  heavi- 
ness, deadness,  coldness,  etc.  There  is  considerable  pain  in  severe  cases 
at  the  site  of  iuflammation,  and  in  the  muscles  and  skin  to  which  the 
nerve  is  distributed.  The  nerve-trunk  and  the  supplied  muscles  are 
usually  tender  on  pressure.  The  nerve  tenderness  is  particularly  promi- 
nent where  the  trunk  is  rigidly  held  by  fibrous  tissues  or  passes  over 
bones.  The  nerve  may  sometimes  be  palpably  enlarged.  Pressure 
upon  it  by  muscular  action  may  also  elicit  tenderness  and  increase  the 
pain.  The  cutaueous  area  of  its  distribution  presents  hyperesthesia  or 
diminished  sensitiveness,   or  both.     Often  there  is  a  feeling  of  painful 


INJURIES  AXD  DISEASES  OF  SPINAL  NERVES.  281 

sensitiveness  when  tactile  perception  is  actually  blunted.  After  degen- 
eration starts  in  the  nerve,  anesthesia  is  present  in  the  skin  supplied  by 
the  nerve,  though  irritation  at  the  site  of  original  lesion  may  still  lead 
to  complaints  of  peripheral  pain,  constituting  cmedJiesia  dolorosa.  The 
striking  feature  of  all  these  sensory  disturbances  is  their  constancy 
and  uniformity  in  a  given  case.  Stabbing  pains  and  momentary  pares- 
thesia are  wanting.  As  the  inflammation  progresses  the  conductivity  of 
the  nerve  decreases,  hyperesthesia  becomes  anesthesia,  and  paresis  passes 
into  paralysis.  The  anatomical  distribution  of  the  sensory  features  is 
very  important.  Often  it  can  be  mapped  out  with  the  greatest  pre- 
cision, but  at  first  usually  the  margin  of  the  area  of  disturbed  sensation 
is  not  so  sharply  defined  and  the  entire  limb  may  be  painful  and  sensi- 
tive. 

The  paralytic  muscles  are  those  which  are  supplied  by  the  given 
nerve.  Opposing  muscles  may  lack  force  from  the  loss  of  proper  bal- 
ance, or  their  use  may  be  inhibited  by  pain.  Delicate  finger-motions 
are  rendered  clumsy  by  the  sensory  disturbance  or  the  loss  of  power, 
or  by  both  combined. 

if  the  lesion  be  sufficiently  severe  to  set  up  degenerative  changes  in 
the  nerve,  we  find  the  trophic  losses  in  the  skin  and  muscles  described 
under  Division  of  Nerves,  page  277.  These  may  be,  and  often  are,  present 
in  a  modified  degree  when  motor  and  sensory  functions  are  not  com- 
pletely gone.  In  all  cases  of  long  standing  they  are  sure  to  appear. 
With  them  go  the  various  other  symptoms  already  described  :  the  loss  of 
muscle  reflexes,  the  electrical  changes  of  irritation,  degeneration  or  destruc- 
tion, and  the  development  of  contractures.  In  complete  division  of 
nerves  the  nutritional  di^urhance  is  usually  a  simple  atrophy,  but  in 
neuritis  there  is  a  wider  range  of  dystrophic  conditions.  These  are 
most  marked  in  the  hands  and  feet  and  most  apparent  in  the  dermal 
structures,  though  the  muscular  wasting  is  sufficiently  apparent  and  often 
most  striking.  In  some  cases  there  is  much  obscuring  edema,  due  to  the 
lack  of  vascular  and  muscular  tone.  In  these  cases  and  in  those  in 
which  redness  and  profuse  perspiration  are  present,  the  dermal  epithelium 
and  the  hairs  and  nails  often  take  on  an  excessive  growth.  As  a  rule, 
the  nails  become  roughened,  scaly,  and  strongly  curved.  The  cushions 
at  the  tips  of  the  fingers  waste  and  the  nails  may  curve  over  toward 
the  palmar  surface,  like  claws.  About  the  base  of  the  nails  the  skin  is 
often  thin,  glazed,  and  red,  and  the  entire  digit  may  be  reduced  to  a 
tapering,  stick-like  appendage,  closely  covered  with  atrophic  skin,  which 
no  longer  shows  the  natural  folds  and  wrinkles  about  the  articulations. 
Abrasions  do  not  heal  readily.  Herpetic  eruptions  are  likely  to  appear, 
and  deep  ulceration  may  follow  unless  unusual  care  be  exercised  to  pre- 
vent irritation  and  infection.     In  some  cases  the  nails  are  cast  off. 

From  inaction  and  the  tendency  to  contracture  in  atrophied  muscles 
and  their  unapposed  antagonists,  the  range  of  joint-motion  in  chronic 
cases  is  usually  diminished.  Trophic  disturbances  in  th.e  joints  are  also 
encountered,  with  the  formation  of  adhesions,  and  false  ankylosis.  In 
rare  cases  joint-effusion  and  other  neurotic  arthropathies  have  been  seen. 

Should  the  neuritis  ascend  to  the  plexus  and  implicate  other  nerves, 
similar  conditions  are  induced  in  their  peripheral  parts. 


282  DISEASES  OF  SPINAL  MENINGES  AND  SPINAL  NERVES. 

Diagnosis. — The  diagnosis  of  a  neuritis  presents  usually  but  little 
trouble.  If  the  dysesthesia  be  confined  to  the  anatomical  limits  of  a 
given  nerve  or  group  of  nerves,  and  the  muscular  disability  is  limited 
to  the  muscles  innervated  by  the  same  nerve,  the  conclusion  is  obvious. 
Too  much  importance  can  not  be  given  to  the  study  of  the  cutaneous  dis- 
tribution of  the  sensory  disturbance.  If  this  area  corresponds  with  that 
of  any  special  nerve  (see  Figs.  15  and  16),  suspicion  of  a  neuritis  or 
nerve  injury  should  be  at  once  aroused.  If  the  corresponding  reflexes  are 
gone,  or  in  slight  and  rare  instances  are  even  exaggerated,  and  if  the 
degenerative  or  irritative  electrical  responses  are  present,  the  suspicion 
is  confirmed.  Sensitiveness  of  the  paralytic  muscles  and  of  the  sup- 
plying nerve-trunk  are  also  important  indications,  and  occasionally  the 
thickened  nerve  can  be  felt.  A  wound  or  contusion  over  the  nerve  is 
of  capital  significance.  The  question  often  arises  in  traumatic  cases  as 
to  whether  the  nerve  has  been  completely  divided.  If  the  reaction  of 
degeneration  is  present  three  or  four  weeks  after  the  injury,  the  nerve  is 
not  totally  divided.  In  the  case  of  division  no  electrical  responses  are 
obtainable  after  a  month.  Many  cases  of  neuralgia  are  confounded 
with  neuritis.  The  distinction  depends  mainly  on  the  darting,  fleeting, 
changing  character  of  neuralgic  j)ains  and  the  presence  of  the  painful 
points  of  Valleix.  Muscular  wasting  or  electrical  changes  and  altered 
reflexes  demonstrate  a  neuritis. 

Prognosis. — The  course  of  a  neuritis  depends  npon  its  cause  and 
the  amount  of  damage  done  the  axis-cylinders  of  the  nerve.  The  gen- 
eral tendency  is  to  restoration  of  healthy  function  as  soon  as  the  cause 
is  removed.  A  slight  neuritis  may  pass  away  within  two  or  three  weeks, 
but  if  the  lesion  has  resulted  in  degeneration  of  the  nerve,  months  will 
be  required  for  the  regenerative  process.  The  faradic  muscle  responses 
aiford  a  good  basis  for  estimating  the  probable  duration  of  a  case.  If 
the  muscles  contract  fairly  to  a  moderate  current  two  weeks  after  an 
acute  attack,  the  disease  will  probably  not  last  over  a  month  or  two.  If 
they  do  not  respond  to  a  strong  faradic  shock,  six  to  nine  months  will 
be  required.  In  long-standing  cases  the  persistence  or  reappearance  of 
faradic  excitability  is  a  favorable  sign  for  complete  recovery.  On  an 
average,  traumatic  cases  do  better  than  those  arising  from  extending  in- 
flammations, especially  if  they  are  of  a  septic  character.  Should  there 
appear  an  upward  extension  of  the  neuritis  the  outlook  is  less  favorable. 
The  presence  of  any  predisposing  cause  also  diminishes  the  prospect  of 
early  recovery,  and  when  the  neuritis  is  due  to  a  new  growth  the  prog- 
nosis is  unfavorable  except  in  syphilitic  cases. 

Treatment  is  naturally  first  directed  to  any  discoverable  cause,  and  the 
predisposing  conditions  must  not  be  neglected.  Gout,  rheumatism,  lead 
infection,  nephritis,  diabetes,  tuberculosis,  the  use  of  alcohol,  the  presence 
of  anemia,  malaria,  or  any  cachexia  must  be  corrected  as  far  as  possible,  and 
the  general  physical  health  brought  to  its  best  level.  Wounds,  septic  in- 
flammations, and  new  growths  require  surgical  intervention.  Pressure  by 
crutches,  clothing,  and  surgical  appliances  must  be  discontinued.  Pain  is 
ordinarily  the  most  pressing  complaint.  It  must  be  controlled  as  far  as 
possible  by  securing  complete  rest,  in  severe  cases  by  immobilizing  the 


INJURIES  AND  DISEASES  OF  SPINAL  NERVES.  283 

parts.  Muscular  action,  rude  massage,  and  vigorous  electrical  stimulation 
produce  pain,  work  harm,  and  should  be  avoided.  On  the  other  hand, 
gentle  passive  movements  and  muscle  kneadings  that  do  not  cause  dis- 
comfort, repeated  daily  or  twice  daily,  are  of  distinct  service  in  main- 
taining the  nutrition  of  the  parts  that  are  temporarily  deprived  of 
their  proper  innervation.  To  this  end  the  employment  of  electricity 
should  be  instituted,  if  possible  from  the  first  day.  Ordinarily  the  gal- 
vanic current  should  be  used,  as  it  is  least  painful  and  most  active. 
Only  slight  muscular  contractions  should  be  produced,  and  fatiguing 
the  muscles  must  be  avoided.  If  the  faradic  coil  can  be  used  without 
causing  pain  and  the  muscles  respond  to  it,  there  is  no  objection  to  its 
use.  The  purpose  to  be  kept  in  view  is  to  maintain  the  responsiveness 
of  the  muscles  to  their  weakened  innervation,  or,  if  that  is  cut  oif,  to 
maintain  them  in  the  best  possible  nutritional  and  responsive  state  for 
the  return  of  the  slightest  influence  of  the  spinal  cord  that  is  able  to 
first  reach  them  through  the  blocked  conduction  of  the  injured  nerve. 
These  local  measures  also  serve  to  overcome,  so  far  as  may  be,  the  vaso- 
motor and  trophic  disturbances  in  the  skin. 

The  use  of  anodynes  calls  for  mature  judgment.  They  should  be 
postponed  to  the  latest  moment,  as  in  cases  demanding  them  a  protracted 
attack  is  commonly  in  hand  and  the  danger  of  installing  a  drug  habit  is 
very  great.  Counterirritation  by  sinapism,  thermocautery,  or  small 
blisters  over  the  nerve  is  useful  in  the  early  stages  if  it  can  be  made 
reasonably  near  the  point  of  inflammation.  It  should  never  be  made 
in  the  cutaneous  areas  supplied  by  the  affected  nerve,  as  it  is  likely  to 
produce  uncontrollable  ulceration. 

In  ehronic  cases  massage,  douching  with  hot  and  cold  water,  elec- 
tricity, and  counterirritation  are  of  great  value.  Strychnin  in  large  doses 
and  hypodermatically  sometimes  is  of  use.  The  use  of  iodids  or  of  mer- 
cury is  of  questionable  utility  unless  indicated  by  constitutional  conditions, 
though  mercurial  inunctions  along  the  course  of  the  nerve  have  seemed 
to  assist  in  some  refractory  cases.  Contractures  and  distorted  joints 
should  be  treated  orthopedically.  Muscles  that  are  wasted  and  weak- 
ened may  be  of  some  service  if  not  placed  at  complete  mechanical  dis- 
advantage by  flexed  joints  and  overacting,  strong  antagonists.  Dropped 
foot,  dropped  wrist,  flexed  knee,  and  flexed  hip  should  be  obviated  by 
early  and  persistent  attention,  by  massage,  and,  if  need  be,  by  splints 
and  fixation  apparatus.  Secondary  contracture  sometimes  appears  in 
the  muscles  of  the  extremities  after  regeneration  of  nerves  injured  by 
neuritis,  just  as  it  does  in  the  face,  but  the  balance  is  less  delicate  and 
distortion  does  uot  result  so  readily. 

Nerve- tumors. — Spinal  and  cranial  nerves  may  present  new 
growths  of  various  sorts.  In  one  group  may  be  included  those 
neoplasms  which  are  common  to  all  tissues,  such  as  fibroma,  myxoma, 
sarcoma,  tubercle,  syphiloma,  carcinoma,  etc.  To  another  we  should 
restrict  those  nerve-growths  made  up  largely  of  nerve-fibers  or  nerve- 
cells,  and  these  only  may  properly  be  called  neuromata.  In  addition 
there  are  mixed  and  transition  forms.  In  the  first  group  the  tumors 
are  commonly  secondary  and  usually  single.     In  neuromata  the  tumors 


284  DISEASES  OF  SPINAL  MENINGES  AND  SPINAL  NERVES. 

are  commonly  multiple  and  the  condition  is  often  hereditary  and  may 
be  congenital  or  may  follow  traumatism. 

Of  neuromata  a  number  of  varieties  are  encountered  M^hich  have 
received  descriptive  names.  Those  made  up  of  ganglion-like  cells  are 
called  ganglion  or  cellular  neuromata.  When  the  nerve-fiber  elements 
are  present  the  term  fibiillar  neuroma  is  used,  and  this  is  further  divided 
into  the  myelinie  and  amyelinic  sorts,  depending  upon  the  presence  or 
absence  of  the  myelin  constituent.  The  adjectives  terminal,  central, 
peripheral,  multiple,  telangiectoid,  and  cirsoid  are  merely  descriptive  of 
location  or  form. 

Certain  terminal  neuromata  which  seem  to  be  greatly  enlarged 
Pacinian  bodies  constitute  very  painful  tubercles  under  the  skin,  and  to 
these  the  term  neuromata  dolorosa  has  been  applied  by  Virchow. 

The  multipde  neuromata  constitute  an  imjjortant  group.  In  some 
cases  they  number  thousands,  and  vary  in  size  from  small  peas  to 
masses  as  large  as  a  fist.  They  are  located  in  three  general  ways  :  (1) 
They  may  appear  along  a  single  or  along  several  nerve-trunks  at  somewhat 
regular  intervals,  like  beads  ;  (2)  they  may  appear  only  on  a  single 
nerve  and  its  branches,  and  (3)  they  may  invade  nearly  every  nerve 
in  the  body,  including  the  sympathetic.  In  subcutaneous  situations 
they  appear  like  vascular,  cirsoid  dilatations,  but  present  a  different 
consistency  and  anatomical  position,  and  are  not  modified  by  pressure 
on  venous  or  arterial  channels.  They  are  most  frequently  acellular 
and  devoid  of  myelin.  While  they  may  be  sensitive  and  attended 
by  neuralgic  pains,  they  are  usually  unmarked  by  any  sensory  dis- 
turbance. As  above  indicated,  such  cases  are  sometimes  of  a  heredi- 
tary nature. 

Traumatic  neuromata  are  rather  common  and  their  frequency  after 
surgical  operations  has  given  rise  to  the  term  ampjvtation  neuroma.  A 
nerve  involved  in  scar-tissue  by  the  healing  process  is  likely  to  develop 
such  a  neuroma.  In  amputated  limbs  the  nerve-stumps  become  clubbed, 
and  upon  examination  there  is  found  an  increase  in  the  nerve-fibers  and 
axis-cylinders,  which  have  a  tendency  to  turn  up  and  twist  about  in  the 
small  tumor,  the  size  of  which  is  relative  to  that  of  the  nerve  on  which 
it  develops.  It  appears  to  be  but  the  thwarted  natural  effort  of  the 
central  portion  of  a  divided  nerve  to  extend  downward.  Such  trau- 
matic neuromata  are  often  exquisitely  sensitive  and  may  prevent  the 
use  of  artificial  limbs,  besides  causing  much  neuralgic  suffering. 

Neuromata  in  the  limited  sense  of  the  term  are  benign  growths,  but 
occasionally  after  irritation  or  partial  surgical  removal  sarcomatous  con- 
ditions appear.  From  their  number,  and  rarely  from  their  position,  as 
within  the  vertebral  canal  or  cranium,  or  on  the  pneumogastric  nerve, 
they  may  prove  fatal.  True  neuromata  are  often  associated  with  skin 
tumors  and  cutaneous  brownish  circumscribed  pigmentations.  Preble 
and  Hektoen  ^  from  the  clinical  side  divide  cases  of  multiple  neuromata 
into  four  groups  which  may  be  variously  comlnned  in  a  given  individual : 
(1)  tumors  of  the  skin,  (2)  tumors  of  the  nerves,  (3)  pigmentation  of  the 
skin,  (4)  functional  disturlmnces. 

^  "  Amer.  Jour.  Med.  Sciences,"  Jan.,  1901. 


INJURIES  AND  DISEASES  OF  SPINAL  NERVES.  285 

Etiology. — In  traumatic  neuromata,  and  especially  the  amputation 
variety,  tlie  causation  is  readily  understood.  So  is  the  action  of  irritation 
resulting  in  a  fibrous  proliferation  which  may  strangle  the  nerve-tibrils, 
thrust  thcni  asunder,  or  locate  a  filjroid  thickening  on  or  within  the  nerve- 
sheath.  The  hereditary  features  of  multiple  neuromata  do  not  explain  the 
initial  liability  to  this  affection.  They  also  appear  in  myxedematous,  creti- 
noid,an<l  phthisical  conditions, and,  strangely,  are  almost  confined  toniales. 

Symptoms. — Xeuromata  manifest  themselves  by  local  signs  and 
by  motor  and  sensory  symptoms  in  the  distril)ution  field  of  the  invaded 
nerves.  When  situated  on  the  nerve-trunk  they  may  present  much  the 
same  features  as  a  chronic  neuritis  or  local  nerve-injury.  Hyperesthesia, 
paresthesia,  and  motor  and  trophic  loss  are  likely  to  appear  with  the  elec- 
trical formula  of  degeneration.  If  the  ncLroma  is  open  to  palpation,  it 
presents  usually  a  rounded,  dense,  nodular,  more  or  less  sensitive  swell- 
ing. Owing  to  its  attachment  to  the  nerve  it  has  considerable  lateral 
movement,  but  resistance  is  encountered  in  the  opposite  direction. 
Pressure  sometimes  provokes  neuralgic  pains  or  tingling  in  the  sensory 
distribution  of  the  nerve.  Multiple  neuromata,  however,  may  be 
quite  insensitive  and  present  no  sensory,  motor,  or  trophic  disturb- 
ances. They  are  only  to  be  detected  by  the  often  visible  chains  of 
nodular  enlargements  along  the  course  of  the  nerves.  Traumatic  neu- 
romata usually  can  be  readily  palpated  in  the  region  of  scars  and  give 
a  feeling  of  shot-like  bodies  which  are  usually  very  sensitive.  The 
rare,  painful  tubercles  constituting  the  neuromata  dolorosa  variety  are 
readily  palpated  and  give  rise  to  pain  and  tingling  in  the  definite  nerve- 
area  allied  to  their  anatomical  location.  In  some  instances  neuromata 
have  caused  muscular  spasm  in  their  neighborhood,  or  even  at  some 
distance,  and  epileptiform  convulsions  have  been  cured  by  their  re- 
moval. 

Diagnosis. — Neuromata  are  readily  diagnosed  when  a  palpable, 
sensitive  enlargement  is  found  on  a  nerve-trunk  with  sensory  and  motor 
disturbance  below.  In  cases  of  multiple  neuromata  the  diagnosis  is 
apparent.  When  single  and  deeply  situated,  their  presence  may  only 
be  inferred  by  the  slowness  of  the  onset  of  symptoms  and  the  very 
chronic  course  of  the  disease.  At  the  same  time  neuritis  and  pressure 
upon  the  nerve  from  adjoining  new  growths  must,  if  possible,  be 
excluded.  In  this  case,  also,  it  will  be  impossible  to  decide  whether 
the  growth  in  the  nerve  belongs  to  the  first  group  or  is  a  true  neuroma. 
Multiple  neuromata,  traumatic  neuromata,  neuromata  dolorosa,  and  neu- 
romata occurring  in  myxedematous  individuals  are  usually  of  the  true 
and,  hence,  benign  variety. 

Prognosis. — Single  neuromata  are  more  likely  to  damage  the  nerve 
than  the  multiple  variety.  If  the  tumor  is  of  some  size  and  functional 
disturbance  is  absent,  none  is  likely  to  develop,  but  if  such  symptoms 
occur,  they  are  likely  to  increase.  True  neuromata  are  of  slow  develop- 
ment and  present  a  long  course.  Malignant  or  specific  growths  in  nerves 
present  the  same  outlook  as  elsewhere. 

Treatment. — The  treatment  of  neuromata  is  practically  surgical. 
They  must  be  excised  with  as  little  damage  to  the  nerve-trunk  as  possi- 
ble.     In  the  multiple  forms  surgical  interference  is   hardly  practicable 


286  DISEASES  OF  SPINAL  MENINGES  AND  SPINAL  NERVES. 

except  for  isolated  masses,  or  to  relieve  special  nerves.  If  the  tumor  is 
confined  to  the  nerve-sheath,  it  may  be  removed  without  much  injury  to  the 
nerve-trunk,  but  if  this  is  involved,  the  neuroma  must  be  exsected  and  the 
ends  of  the  nerve  sutured.  This  is  now  accomplished  even  when  several 
inches  of  the  nerve  are  removed,  by  interposing  pieces  of  nerves  removed 
from  animals,  or  by  catgut  bundles,  bone  tubes,  etc.  There  is,  however,  a 
decided  liability  to  recurrence  of  neuromata  after  surgical  interference,  due 
to  the  preexisting  tendency  and  the  irritant  conditions  set  up  by  operation 
and  healing.  Nerve-stretching  is  claimed  to  be  more  efficient  in  relieving 
the  reflex  spasms  than  exsection.  The  use  of  anodynes  for  the  relief  of 
the  neuralgic  pains  that  sometimes  make  life  burdensome  should  never  be 
resorted  to  if  the  neuroma  can  be  surgically  dealt  with.  Pressure  on  the 
nerve  above  the  tumor  sometimes  gives  temporary  relief  from  pain. 


CHAPTER  III. 

LESIONS  OF  SPECIAL  SPINAL  NERVES. 

Any  spinal  nerve  may  be  singly  injured  by  trauma  or  disease,  or 
several  neighboring  nerves  may  be  involved  at  the  same  time  by  local 
conditions.  Such  lesions  give  rise  mainly  to  disturbance  of  sensa- 
tion, motion,  and  trophic  control,  showing  themselves  in  varying 
degree  in  the  cutaneous  and  muscular  distribution  of  the  injured  nerves. 
The  changed  electrical  conditions  and  the  modified  muscle  reflexes  that 
are  also  present  equally  depend  upon  the  extent  and  nature  of  the  lesion. 
These  common  lesions  are  division,  neuritis,  degeneration,  and  new 
growths,  which  have  been  considered  in  general  terms  in  the  preceding 
chapter.  Irritant  lesions  produce  morbidly  exaggerated  functions,  such 
as  spasms,  hyperesthesias,  pain,  and  rarely  hypertrophy,  while  destructive 
lesions  are  marked  by  conditions  of  deficit,  anesthesia,  paralysis  or 
paresis,  dystrophy,  and  atrophy.  These  are  often  blended  in  the  same 
case,  as  by  the  partial  division  of  a  nerve,  or  by  a  neuritis  affecting  mainly 
the  motor  or  sensory  portions  of  the  nerve.  For  the  sake  of  brevity, 
and  to  avoid  repetition,  these  various  nerve-lesions  will  be  described 
systematically  :  (1)  As  to  commonly  acting  causes  ;  (2)  as  to  the  resulting 
motor  disability  and  deformity,  and  (3)  as  to  the  sensory  disturbance. 
A  lesion  of  a  disabling  degree  will  be  understood  to  be  in  operation 
unless  otherwise  indicated.  Lesser  injuries  will,  of  course,  present 
relatively  diminished  symptoms. 

THE  CERVICAL  AND  BRACHIAL  PLEXUSES. 

The  phrenic  nerve  is  impaired  :  (1)  By  disease  of  the  cervical 
vertebrae  or  of  the  meninges  or  of  the  cord,  affecting  its  spinal  nuclei  or 
roots.  The  condition  is  then  usually  bilateral,  and  other  muscles  than 
the  diaphragm  commonly  suffer.  (2)  In  the  neck  penetrating  wounds 
may  reach  this  nerve,  or  new  growths  injure  it.  (3)  In  the  thorax 
tumors  may  compress  it  and  inflammations  extend  to  it. 


Diagram  showing  Relations  and  Distkibutio: 


..<^ 


Plate  I. 


-sr   nK— . 


(F  Ckrvical  and  Brachial  Nerves  (Flower). 


LESIONS   OF  SPECIAL  SPINAL  NERVES.  287 

The  resulting  motor  loss  consists  of  inactivity  of  the  diaphragm  on 
the  affected  side,  which  fails  to  descend  on  inspiration,  and  the  corre- 
sponding portion  of  the  abdominal  wall  does  not  advance  equally  with 
that  of  the  sound  side.  This  is  especially  noticeable  on  deep  inspiratory 
efforts.  When  both  phrenics  are  involved,  the  breathing  is  of  a  costal 
sort,  and  any  exertion  quickly  causes  respiratory  distress.  Difficulty  in 
expectoration,  sneezing,  defecation,  and  other  abdominal  expulsive  efforts 
is  also  present. 

The  sensory  disturbance  is  obscure  and  often  overlooked  or  mis- 
construed as  intercostal  neuralgia,  muscular  rheumatism,  etc. 

The  posterior  thoracic  in  its  long  course  from  the  fifth  and  sixth 
cervical  nerves  to  its  distribution  in  the  serratus  magnus  is  often  sub- 
jected to  mechanical  pressure  from  heavy  objects  carried  on  the  shoulder 
and  by  muscular  compression  in  severe  exertion  or  continued  labor,  par-, 
ticularly  in  overhead  work.  Mowing  and  tailoring  also  furnish  cases. 
Penetrating  wounds  occasionally  involve  it,  and  falls  or  blows  on  the 
back  may  injure  it.  It  also  suffers  in  association  with  other  nerves  as 
a  part  of  spinal  atrophies.  From  the  usual  traumatic  character  of  the 
disease,  men  in  active  middle  life  are  most  commonly  affected,  and  on 
the  right  side,  as  a  rule. 

It  occasions  loeakness  in  all  the  movements  of  the  upper  extremity 
that  depend  upon  the  fixation  of  the  scapula  and  impairs  thoracic  in- 
spiratory expansion  on  the  same  side,  but  causes  no  absolute  motor  loss. 
The  paralysis  of  the  serratus  causes  a  peculiar  and  characteristic  de- 
formity. Attempts  to  put  the  arm  forward  cause  the  posterior  border 
of  the  scapula  to  widely  wing  out  from  the  chest,  so  that  a  deep  recess 
is  formed  behind  the  shoulder-blade.  The  upper  portion  of  the  bone 
moves  outward  and  the  lower  angle  toward  the  spine. 

As  the  nerve  is  almost  purely  motor,  the  only  sensory  disturbance 
is  neuralgic  pain  in  the  neck  and  shoulder  in  neuritic  cases.  The  prog- 
nosis in  injury  to  the  posterior  thoracic  is  comparatively  less  favorable 
than  in  other  spinal  nerves.  A  serratus  paralysis  is  always  of  long  dura- 
tion and  often  permanent,  even  when  there  is  every  reason  to  believe 
that  the  condition  has  arisen  from  a  simple  pressure  neuritis. 

The  suprascapular  nerve  arises  from  the  fourth,  fifth,  and  sixth 
cervical  nerves.  It  may  suffer  alone  in  shoulder  dislocations.  The  supra- 
and  infraspinati  are  paralyzed  and  the  scapula  becomes  subcutaneous 
by  their  atrophy.  The  arm  can  not  rotate  outward  at  the  shoulder,  and 
there  is  a  general  lack  of  balance  with  weakness  in  the  movements  of 
the  member.  Carrying  the  hand  from  within  outward,  as  in  writing,  is 
rendered  especially  uncertain  and  difficult.  Anesthesia  over  the  outer 
portion  of  the  scapula  and  the  posterior  portion  of  the  deltoid  is  often 
present.  Usually  the  suprascapular  nerve  and  the  circumflex  are  con- 
jointly injured. 

The  circumflex  nerve,  arising  from  the  fifth,  sixth,  and  seventh 
cervical  nerves,  descends  in  the  posterior  cord  of  the  brachial  plexus, 
which  it  leaves  to  pass  outward  under  the  subscapular  muscle,  winds 
around  the  humerus,  and  is  distributed  to  the  tei^es  minor  and  the  del- 
toid.    It  also  supplies  the  shoulder-joint.     It  furnishes  sensation  to  the 


288 


DISEASES  OF  SPINAL  MENINGES  AND  SPINAL  NERVES. 


Fig.  103. — Atrophy  of  the  deltoid  and  deformity 
of  the  shoulder  in  paralysis  of  the  circumtiex 
nerve. 


skin  in  a  chevron -shaped  area  over  the  lower  two-thirds  of  the  deltoid. 
From  its  exposed  position  on  the  neck  of  the  humerus  and  in  the  axilla 
it  is  often  injured  by  shoulder  dislocations,  by  arthritis,  by  crutch  pres- 
sure, and  by  falls  or  blows  on  the  shoulder.  Injury  of  the  circumflex 
causes  loss  of  action  on  the  part  of  the  deltoid,  and  all  attempts  fail  at 
lateral   extension   of  the  arm  from  the  body.     The  loss  of  the  teres 

minor  action  is  in.si^nificant. 

Owing  to  the  deltoid  atrophy 
the  acromion  is  uncovered  and  the 
shoulder  rendered  pointed  and 
angular.  The  head  of  the  hum- 
erus can  readily  be  felt  from  the 
lateral  aspect.  In  some  instances 
it  drops  from  its  socket, leaving  a 
deep  furrow  under  the  acromion. 
The  nutrition  of  the  joint  also 
suffers  and  arthritis  is  likely  to 
develop,  limiting  the  range  of 
joint  motion.  When  the  arm  is 
passively  moved,  the  scapula  does 
not  follow  it  unless  joint  disease 
is  also  present.  An  initial  arth- 
ritis, by  involving  the  articular 
branches,  may  spread  to  the  cir- 
cumflex and  disable  the  deltoid. 
Anesthesia  in  the  distribution  field  of  the  circumflex  over  the  lower 
two-thirds  of  the  deltoid  is  usually  present. 

The  musculospiral  nerve  is  the  most  frequently  injured  nerve  in 
the  arm,  perhaps  in  the  body.  Arising  from  the  posterior  brachial 
cord,  it  winds  around  the  humerus  in  the  musculospiral  groove  under 
the  triceps,  where  it  is  subject  to  muscular  compression  and  external 
violence  or  pressure.  It  supplies  all  the  extensors  of  the  elbow,  wrist, 
and  fingers,  both  the  supinators,  and  through  its  radial  branch  the  skin 
on  the  dorsal  surface  of  the  thumb  and  two  radial  fingers,  and  the  pos- 
terior radial  border  of  the  hand.  It  also  furnishes  articular  filaments  to 
the  wrist  and  carpal  joints.  By  cutaneous  branches  given  off  above  those 
to  the  triceps  it  supplies  the  skin  in  an  area  extending  from  the  wrist  in 
a  narrow  but  widening  strip  up  the  dorsum  of  the  forearm,  and  over  the 
outer  aspect  of  the  arm  as  high  as  the  insertion  of  the  deltoid.  These 
branches,  however,  are  seldom  involved  in  a  musculospiral  palsy.  This 
nerve  is  injured  in  a  variety  of  ways,  and  is  especially  involved  in  systemic 
states,  such  as  lead  poisoning.  In  these  latter  conditions  it  is  interesting 
to  note  that  the  supinator  longus,  ^^hich  is  an  active  flexor  of  the  elbow, 
does  not  participate.  From  its  exposed  position  in  the  axilla,  crutch 
pressure  and  dislocation  of  the  humerus  frequently  aifect  it ;  lower 
down  on  the  shaft  of  the  humerus  it  is  injured  by  fractures,  nipped  by 
callus,  and  subject  to  contusions  from  blows.  Here  it  is  frequently 
compressed  injuriously  by  constricting  cords  about  the  arm,  sometimes 
by  violent  action  of  the  triceps,  often  by  pressure  during  sleep  with  the 
arm  under  the  body  or  resting  on  some  hard  object,  as  a  chair-back,  door- 


LESIONS   OF  SPECIAL   SPINAL  NERVES. 


289 


Fig.  104. — Characteristic  iiositiou  of  hand  in  musculospiral 
palsy. 


step,  or  bench.  Such  sleep  'pahy  is  sometimes  presented  after  the  pro- 
longed stupor  of  drunkeness,  surgical  anesthesia,  or  narcotism.  Direct 
blows  to  the  arm  may  also  produce  musculospiral  palsy,  and  cold  is  often 
accredited  as  a  cause. 

The  motor  sympioms  of  disease  of  the  musculospiral  nerve  are  exten- 
sive, interesting,  and  char- 
acteristic. The  elbow  and 
wrist  can  not  be  extended, 
and  the  long  extensors  of  all 
the  digits  and  the  supinators 
of  the  hand  are  inactive  after 
a  lesion  near  the  armpit. 
When  the  nerve  is  aifected 
in  the  musculospiral  groove, 
the  usual  location,  the 
branches  to  the  triceps  es- 
cape and  elbow  extension  is 
preserved.  In  lesions  at  or 
below  the  lower  third  of  the 
humerus  the  branch  to  the 

supinator  longus  escapes,  as  it  does  in  systemic  affections.  The  wrist  can 
not  be  extended  and  wrist-drop  is  produced.  The  fingers  are  semiflexed 
and  can  only  be  extended  by  the  action  of  the  interossei — which  are  sup- 
plied by  the  ulnar — after  the  first  phalanges  are  passively  extended  on  the 
metacarpals.  The  thumb  lacks  extension  movements,  and  those  of  the 
fingers  progressively  diminish  from  the  index  to  the  little  finger.  Fre- 
quently on  the  back  of  the  carpus 
there  develops  a  synovial  tumor 
due  to  the  overcarpal  flexion,  the 
inadequate  support  of  the  extensor 
tendons,  and  perhaps,  in  part,  to 
the  implication  of  the  articular 
branches  of  the  nerve.  This  con- 
stitutes a  dense,  painless  elevation 
that  exaggerates  the  wrist-drop 
deformity.  Unbalanced  by  the 
extensor  paralysis  the  flexors  are 
weakened  so  that  the  hand-grasp 
is  reduced  in  strength  more  than 
half.  The  muscular  wasting 
shows  most  on  the  dorsal  sur- 
face of  the  forearm.  In  those 
cases  that  involve  the  long  sup- 
inator a  very  striking  loss  of 
contour  is  presented.  The  tri- 
ceps may  also  show  diminished  proportions. 

Semory  disturbance,  in  comparison  with  the  extent  of  the  paralysis,  is 

very  slight.     Reference  to  the  diagrams  of  cutaneous  sensation  (Figs.  15 

and  16)  will  give  an  idea  of  the  average  space  supplied  by  the  radial 

branch  of  the  musculospiral,  but  it  varies  widely  in  different  individuals. 

19 


Fig.  lOo. 


-Dropped  wrist  from  luiisciilospiral  palsy, 
showing  retrocarpal  tumor. 


290 


DISEASES  OF  SPINAL  MENINGES  AND  SPINAL  NERVES. 


The  close  relation  with  the  median  and  ulnar  also  obscures  the  outlines 
of  the  field  of  disturbed  sensation.  One  of  the  usual  distributions  of 
these  nerves  is  indicated  in  figure  106.  Often  only  prickling  or  slight 
numbness  is  felt  in  the  tips  of  the  thumb  and  index  finger ;  in  other 
cases  the  anesthesia  is  complete  and  sharply  limited.  In  neuritic  cases 
there  is  often  complaint  of  constant  pain  in  the  wrist  and  carpal  joints, 
which  may  be  slightly  swollen. 

It  is  particularly  in  the  treatment  of  dropped  wrist  that  the  great 
value  of  maintaining  a  proper  position  of  the  articulations  may  be  em- 
phasized. The  tendency  to  carry  the  arm  in  a  flexed  attitude  and  the 
unopposed  action  of  the  flexors  and  pronators  of  the  wrist  give  the 
carpal  articulations  a  vicious  position  that  is  often  difficult  to  overcome, 
and  upon  convalescence  mechanically  defeats  the  returning  strength  of 
the  extensors.  The  use  of  a  carefully  padded  and  loosely  applied  ante- 
rior splint  to  maintain  the  wrist  and  fingers  in  line  with  the  forearm 
hastens  recovery  in  recent  and  in  protracted  cases. 

The  median  nerve  arises  in  front  of  the  axillary  artery  by  roots 
from  the  outer  and  inner  cords  of  the  brachial  plexus.  It  follows  the 
brachial  artery  to  the  bend  of  the  elbow,  but  gives  ofl'  no  branches  above 

that  joint.  It  supplies  all  the  flexors  on  the 
front  of  the  forearm  except  the  flexor  carpi 
ulnaris  and  the  ulnar  portion  of  the  deep 
flexor  of  the  fingers.  It  also  supplies  both 
pronators.  In  the  hand  it  supplies  the 
abductor,  opponens,  and  short  flexor  of  the 
thumb,  and  the  first  and  second  lumbrical 
muscles.  These,  like  the  interossei,  are 
accessory  to  the  flexors  of  the  fingers  for 
motions  of  flexion  at  the  first  joints,  but  are 
aids  to  the  common  extensor  for  extension 
of  the  second  and  third  phalanges.  The 
cutaneous  distribution  is  subject  to  the  dif- 
ferences pointed  out  above.  In  a  general 
way  we  may  say  that  the  median  supplies  the 
radial  half  of  the  hand  on  the  palmar  side 
and  the  tips  of  the  index  and  middle  fingers  on  the  dorsal  aspects.  The 
median  is  rather  rarely  injured  alone,  but  commonly  suffers  with  the  ulnar, 
or  with  the  ulnar  and  muscalospiral,  from  injury  in  or  about  the  axilla. 
It  may  be  divided  by  stab  or  bullet  wounds  in  the  arm,  or  fractures  and 
wounds  in  the  forearm,  especially  near  the  wrist,  and  by  sprains  or  dis- 
locations of  the  wrist.  It  has  been  torn  across  in  compound  Colles'  frac- 
tures. Carrying  heavy  weights  or  holding  objects  for  a  long  time  in  the 
bend  of  the  elbow  may  set  up  a  median  neuritis  by  compression. 

Motor  Symptoms. — Disabling  injury  of  this  nerve  destroys  prona- 
tion, and  the  thumb  can  not  be  rolled  into  the  hand  nor  opposed  to  the 
tips  of  the  fingers.  The  fingers  can  not  be  flexed,  excepting  the  ring 
and  little  fingers,  which  still  act  to  the  ulnar  portion  of  the  flexor  pro- 
fundus and  the  interossei.  The  wrist  is  flexed  weakly  to  the  ulnar  side 
by  the  flexor  carpi  ulnaris.  Through  the  action  of  the  interossei  the 
fingers  can  still  be  flexed  at  the  metacarpophalangeal  joints. 


Fig.  106. — Distribution  of  sensory- 
nerves  on  the  backs  of  the  fingers. 
r,  Musculospiral  nerve;  u,  ulnar 
nerve ;  m,  median  nerve  (Krause). 


LESIONS  OF  SPECIAL   SPINAL   NERVES. 


291 


The  resulting  deformity  consists  in  a  flattening  of  the  hand  through 
loss  of  the  thenar  eminence,  and  the  thumb  lies  in  adduction  parallel  to 
the  index  in  the  same  plane  with  the  fingers,  producing  the  "  ape  hand." 
This  is  also  the  usual  deformity  in  progressive  spinal  muscular  atrophy. 
The  little  linger  retains  all  its  lateral  and  other  motions.  The  presence  of 
the  hypothenar  eminence  and  the  preservation  of  the  ulnar  side  of  the 
hand  are  distinctive.  The  swelling  curve  on  the  ulnar  side  of  the  fore- 
arm also  disappears,  and  a  concave  outline  may  be  presented  extending 
from  the  inner  condyle  to  the  wrist.  From  the  action  of  the  interossei 
there  results  a  tendency  to  forward  subluxation  of  the  first  phalanges  of 
the  index  nnd  middle  fingers  at  the  metacarpophalangeal  joints.  Division 
of  the  nerve  at  the  wrist  only  affects  the  thenar  and  first  two  lumbrical 
muscles  and  the  cutaneous  filaments. 

The  sensory  disturbance  is  sometimes  extremely  slight,  due  to  an 
unusually  extensive  distribution  of  the  ulnar  and  radial  nerves.      It  is 


Fig.  107. — Showing  areas  of  sensory  loss  in  injuries  of  the  median  nerve  (Bowlby). 


most  pronounced  on  the  volar  surface  of  the  index,  but  may  extend  over 
the  area  shown  in  figure  107. 

The  ulnar  nerve  originates  from  the  lowest  cervical  and  the  first 
dorsal  nerves,  and  supplies  in  the  forearm  the  ulnar  flexor  of  the  wrist, 
the  two  inner  divisions  of  the  deep  flexor  of  the  fingers,  and  all  the  small 
muscles  of  the  hand  except  those  innervated  by  the  median — namely, 
the  dorsal  and  palmar  interossei,  the  muscles  of  the  hypothenar  eminence, 
and  the  third  and  fourth  lumbricales.  It  also  supplies  the  adductor  and 
one-half  of  the  short  flexor  of  the  thumb.  Its  cutaneous  branches  sup- 
ply the  ulnar  border  of  the  hand,  front  and  back,  including  all  of  the 
little  finger,  most  of  the  ring  finger,  and  a  varying  portion  of  the  middle 
finger,  largest  on  its  dorsum. 

The  ulnar  is  (1)  rarely  injured  above  the  elbow,  excepting  as  a 
part  of  a  more  general  injury  to  the  brachial  plexus.      (2)  At  the  elbow 


292 


DISEASES  OF  SPIXAL  JIEXIXGES  AXD  SPIXAL  XEEVES. 


its  exposed  position  behind  the  inner  condyle  and  its  superficial  course 
through  the  forearm  and  at  the  wrist  lay  it  lialjle  to  pressure  neuritis 
and  injury  from  wounds  of  all  sorts.  Even  li»ng-coutinued  extreme 
flexion  of  the  elbow-joint,  as  in  sleep,  in  one  predisposed,  may  suffice  to 
mduce  a  neuritis  at  this  point.  Occupations  which  necessitate  continu- 
ous leaning  on  the  elbow  are  also  said  to  be  active  causes,  but  are  cer- 
tainly infrequent  in  this  country.  (3)  Cuts  at  the  wrist  with  various  tools 
or  from  broken  glass  frequently  divide  it. 

Jlofor  Symptoms. — Ulnar  paralysis  constitutes  a  serious  disability  of 
the  hand.  Flexion  at  the  metacarpophalangeal  joints  and  extension  of 
the  second  and  third  phalanges,  which  are  dependent  on  the  interossei  and 
lumbricales,  are  lost.  The  wrist  can  not  be  actively  flexed  to  the  ulnar 
side,  and  the  thumb  is  rotated  toward  the  palm  by  the  abductor  and 
opponens  and  can  not  be  adducted.      The  fingers  lose  all  lateral  motirin. 


Pig.  108. — Showing  sensory  loss  and  ordinary  position  in  injuries  of  the  ulnar  nerve  fBowlby). 


The  distortion  and  deformity  that  result  are  pronounced  and  charac- 
teristic. There  is  overextension  at  tlie  metacarpophalangeal  joints, 
which  makes  the  head  of  the  metacarpal  bones  prominent  in  the  liiilkiwed 
palm.  The  unopposed  flexors  "  claw  "  the  second  and  third  joints,  and 
with  the  strongly-acting  common  extensor  increase  the  deformity.  This 
is  least  marked  in  the  index  and  middle  fingers,  which  do  not  lose  their 
lumbrical  muscles.  All  the  interosseous  spaces  are  emptied,  and  the 
fifth  metacarpal  is  left  entirely  subcutaneous.  In  place  of  the  hypothe- 
nar  prominence  there  is  a  deep  hollow.  The  tinaffected  muscles  of  the 
ball  of  the  thumb  stand  out  prominently  in  contrast  with  the  skeleton- 
like-hand. The  loss  of  sensation  is  confined  to  the  indicated  area  of 
cutaneous  distribution,  but  is  only  complete  in  the  little  finger.  Figure 
108  shows  its  distribution  and  degree. 


LESIONS  OF  SPECIAL   SPINA L   NERVES. 


293 


COMBINED  PALSIES  OF  THE  NERVES  OF  THE  ARM. 
It  is  coniniou  lor  .several  uerves  of  tlie  upper  extremity  to  be  injured 
at  the  same  time,  causing  combined  palsies  presenting  symptoms  of  corre- 
sponding extent.  The  circumflex,  suprascapular,  and  musculocutaneous 
may  be  affected  simultaneously 
by  disease  of  the  fifth  and  sixth 
cervical  nerves,  from  which  they 
arise.  This  is  usually  caused 
by  forcibly  dragging  the  arm 
downward  or  upward,  lacerating 
the  anterior  nerve-roots  ^  and  may 
occur  at  birth.  In  this  lesion  sen- 
sory disturbance  is  usually  absent. 
A  new  growth  or  injury  at  a  point 
between  the  scaleni  muscles  op- 
posite the  sixth  cervical  vertebra 
may  affect  both  spinal  nerves.  At 
this  point  Erb  found  they  could 
be  simultaneously  stimulated  by 
electricity.  The  muscles  involved 
are  the  deltoid,  spinati,  biceps, 
and  brachialis  anticus,  and  the 
sensory  disturbance  corresponds 
to  the  cutaneous  distribution  of 
the  three  nerves  in  question. 
Kennedy  ^    reports     some     such 

birth  accident  instances  greatly  benefited  by  surgical  operation.    A  cica- 
tricial condition  was  found  at  Erb's  point  above  the  clavicle  and  out- 
side   the    sternomastoid    muscle;     the   nerves   were 
p---.„,__^  resected  and  sutured  with  comparatively  early  res- 

toration of  motor  function. 


Fig.  109. — Radicular  palsy  affecting  the  spinati,  del- 
toid, bicep.s,  and  brachialis  anticus. 


^aC*^. 


I 


Fig.  110. — Brachial  plexus  injury.     Area  of  auestlicsia  below  black  line. 


Injuries  to  the  brachial  plexus  usually  involve  more  than  one  nerve 

^  Huet,  Duval,  et  Guillan,  "Rev.  Xeurolog. ,"  Dec.  15,  1900. 
2  "  Br.  Med.  Jour.,"  Feb.  7,  1903. 


294 


DISEASES  OF  SPINAL  3IENINGES  AND  SPINAL  NERVES. 


in  the  arm.  Xerve  injury  arising  from  dislocations  of  the  humerus 
and  from  strains  on  the  arm  usually  implicate  several  nerves.  Thus  the 
median,  ulnar,  and  musculospiral  may  be  injured  together,  or  a  single 
nerve  may  suffer.  In  figure  110  is  shown  a  case  suffering  from  a 
wrench  of  the  arm  received  in  alighting  from  a  moving  street-car. 
The  ulnar,  internal  cutaneous,  nerve  of  Wrisberg,  and  intercosto- 
humeral  were  simultaneously  injured.  The  anesthetic  area  could  be 
distinctly  marked  out.  A  similar  combination  of  nerve-lesions  occurs 
in  birth-palsies  from  pulling  on  the  arm  or  using  a  hook  over  the  neck  or 
in  the  axilla.  Figure  111  shows  the  deformity  in  such  a  case  :  in  a  breech 
presentation  attempts  were  made  to  draw  the  arm  down  from  the  side  of 
the  head  and  resulted  in  injury  to  the  median,  ulnar,  and  musculospiral. 
Fractures  of  the  humerus  may  involve  the  ulnar  with  the  musculo- 
spiral. Fractures  in  the  forearm  may  injure  the  radial  and  ulnar  nerves, 
W'hich,  also,  may  be  simultaneously  implicated  in  Avounds  at  the  wrist. 

In  an  ascending  neuritis  other  associated  nerves  are  likely  to  be 
affected  if  the  inflammation  reaches  the  plexus  (neuritis  migrans).  This 
most  frequently  results  from  infected  wounds.  A  neuritis  traveling  up 
the  median  will  first  invade  the  ulnar  and  musculocutaneous,  and  then 
the  other  nerves  arising  from  the  brachial  plexus.  The  order  in  which 
the  symptoms  arise  is  the  key  to  diagnosis. 

Disease  of  the  cervical  vertebrae,  as  Pott's  disease  ;  of  the  meninges,  as 

cervical  ])achymen- 
ingitis ;  or  disease 
of  the  cord,  as 
syringomyelia,  may 
involve  the  brachial 
nerves  in  varying 
groups. 

Neuritis  of  the 
brachial  plexus  is 
a  rather  common 
condition  that  is 
usually  mistaken  for 
a  neuralgia,  angina 
pectoris,  or  a  rheu- 
matic trouble  in 
the  shoulder  and 
arm.  According  to 
Gowers,  who  first 
carefully  described  it,  brachial  plexus  neuritis  is  analogous  to  sciatic 
neuritis  in  the  lower  extremity. 

Causes. — This  disease  of  the  brachial  plexus  is  encountered  mainly 
after  middle  life,  and  especially  in  rheumatic  and  gouty  subjects.  In 
the  majorit}^  of  cases  there  is  a  history  of  attacks  of  lumbago  or  sciatica 
and  a  strongly  marked  lithemic  heredity.  Women  suffer  more  frequently 
than  men. 

Symptoms. — Pain  is  the  first  and  constant  complaint.  It  is  often 
of  rather  sudden  onset  and  is  likely  to  come  in  paroxysms,  especially  at 


i 


rig.  111.— Brachial  palsy  from  birth-iiijiuy,  due  to  traction  in  axilla. 


LESIONS  OF  SPECIAL  SPINAL  NERVES. 


295 


night,  becoming  more  continuous,  but  still  with  exacerbations.  Motion 
that  stretches  the  plexus,  such  as  elevating  the  arm,  is  sure  to  provoke  it, 
and  any  considerable  use  of  the  member  is  inhibited  by  the  pain  to  which 
it  gives  rise.  The  pain  may  begin  first  in  the  region  of  the  plexus,  in  the 
clavicular  hollows,  or  under  the  scapula,  but  soon  involves  the  entire  arm, 
runs  up  into  the  neck,  and  frequently  aifects  the  side  of  the  chest. 

Upon  manipulation  one  or  all  of  the  nerves  in  the  arm  will  be  found 
tender  to  the  touch,  and  this  tenderness  can  be  traced  through  the  axilla, 
under  the  clavicle,  and  into  the  scaleni  muscles  at  the  side  of  the  neck. 
There  is  often  tenderness  over  the  scapula  in  the  distribution  of  the 
suprascapular  nerve.  The  skin  over  the  arm  is  usually  hypersensitive, 
and  the  constant  dragging  ache  in  the  shoulder  and  arm  is  almost  unen- 
durable. The  patient  is  constantly  trying  to  find  an  easier  position  for 
the  extremity,  but  without  success.  The  tender  muscles  become  flabby  and 
wasted,  and  sometimes  show  slight 
•degenerative  reaction  to  electricity 
in  certain  groups.  Dermal,  epithelial, 
and  vasomotor  disturbances  are  not 
infrequent.  The  reflexes  are  dim- 
inished, rarely  exaggerated. 

Diagnosis. — The  diagnosis  rests 
on  the  continuous  character  of  the 
pain,  the  tenderness  of  nerve-trunks, 
plexus,  and  roots,  and  the  evidences 
of  the  neuritic  process  in  the  dermal 
changes,  the  vasomotor  failure  and 
the  tendency  to,  if  not  the  presence 
of,  muscular  atrophy.  The  presence 
■of  joint  disease  in  old,  gouty,  and 
rheumatic  patients  may  mislead  as  to 
the  order  of  events,  for  the  joint  dis- 
turbance may  be  induced  by  the  neu- 
ritis, or  vice  versa.  The  history  must 
-determine  the  point. 

Prognosis. — Brachial  plexus 
neuritis  is  always  a  protracted 
malady,  requiring  from  three  to 
eighteen  months,  or  more.  In  old 
arthritic  individuals  it  is  especial- 
ly inveterate,  but  usually  termi- 
nates in  recovery.  Relapses  are 
likely  to  take  place,  and  some 
slight  disability  in  the  way  of  pain 
or  weakness  is  likely  to  persist  per- 
manently. The  long  maintenance 
of  flexed  positions,  with  the  double 

tendency  to  joint  disturbance  furnished  by  the  rheumatic  element  and 
the  nerve-lesion,  frequently  result  in  a  limitation  of  the  range  of  motion 
at  the  shoulder  and  elbow.  The  wrist  and  smaller  joints  may  also  be 
-affected,  and  the  use  of  the  hand  considerably  impaired. 


Fig.  112. — Neuritis  of  the  brachial  plexus  on 
left  side  with  wasting  of  arm  and  forearm. 


296  DISEASES  OF  SPIXAL  JIEXIXGES  AND  SPINAL  XEBVES. 

Treatment. — The  treatment  is  that  for  neuritis  with  especial  atten- 
tion to  the  gouty  state.  Repeated  counterirritation  on  the  side  of  the 
neck,  in  the  clavicular  foss«,  and  on  the  inner  aspect  of  the  arm  with 
blisters  or  the  Paquelin  cautery  may  be  used  from  the  first.  The  arm 
shoidd  be  immobilized,  except  for  the  mildest  daily  passive  movements, 
slight  massage,  and  electricity  when  the  tenderness-  and  pain  permit. 

NERVES  OF  THE  TRUNK. 
The  individual  nerves  supplied  to  the  trunk  by  the  thoracic  and  two 
upper  lumbar  pairs  are  rarely  singly  involved.  A  vertebral  lesion  or -a 
wound  raav  so  affect  them,  but  the  motor  loss  is  hardly  appreciable  un- 
less several  suiFer  simultaneously.  The  neuritic  pain  arising  from  Pott's 
disease  and  the  girdling  sensation  in  this  malady  and  in  tabes  dorsalis 
have  great  value  from  a  diagnostic  standpoint.  There  is  also  some  truth 
in  the  lav  apprehension  that  herpes  zoster  may  be  fatal  if  it  completely 
girdles  the  trunk,  as  in  such  instances  it  almost  always  arises  from  some 
implication  of  the  nerve-roots  by  spondylitis,  malignant  growths,  or 
other  seriotis  local  mischief.  Though  irritation  of  a  nerve  may  cause 
a  localized  herpetic  eruption,  in  true  zoster  the  lesion  is  an  inflammatory 
disturbance  of  the  posterior  root  ganglia  (see  page  324). 

THE  NERVES  OF  THE  LOWER  EXTREMITY. 

The  nerves  of  the  lower  extremity  are  much  less  frequently  diseased 
than  those  of  the  arm,  but  are  subject  to  special  accidents  by  pressure 
on  the  lumbar  and  sacral  plexases  within  the  body,  as  from  parturition 
and  abdominal  and  pelvic  growths.  Psoas  abscess  and  inflammations 
of  the  pelvic  viscera  may  also  invade  these  plexuses. 

The  anterior  crural  nerve  may  be  affected  (1)  Avithin  tlie  abdo- 
men, when  the  iliacus  is  affected  and  flexion  of  the  thigh  on  the  body 
is  weakened,  or  (2)  below  Poupart's  ligament.  After  a  paz-a^j/zzn^r  lesion 
the  extensors  of  the  knee  are  inactive  and  wasted  and  the  knee-jerk  is 
abolished.  Difficulty  is  experienced  in  advancing  the  foot,  especially 
in  mounting  stairs.  Anesthesia  extends  from  the  groin  to  the  inner  side 
of  the  foot,  involving  the  entire  extremity  except  the  buttock  and  a 
narrow  strip  down  the  back  of  the  thigh,  which  beloAv  the  knee  spreads 
over  the  outer  side  of  the  calf  and  emljraces  the  foot  excepting  on  the 
inner  margin  (see  diagrams,  pp.  52  and  53).  This  nerve  was  observed 
to  be  affected  seventeen  times  in  1000  patients  in  the  lying-in  hospital 
of  Copenhagen,  in  all  subsequent  to  parturition.  ^ 

The  external  cutaneous  branch  of  the  anterior  crural  supplying 
the  outer  side  of  the  thigh  seems  especially  subject  to  sensory  disturb- 
ances. In  gout,  alcoholism,  tobacco  excesses,  and  sometimes  as  a  linger- 
ing feature  in  multiple  neuritis,  this  area  is  exquisitely  hyperesthetic, 
so  that  the  patient  finds  it  inconvenient  to  even  allow  the  weight  of  the 
trousers  upon  the  skin,  or  is  conscious  of  an  acute  tingling  when  he 
passes  his  hand  over  the  thigh.  This  condition  is  called  meralgia  and 
mav  be  due  to  defective  return  circulation  associated  with  varicose  veins 
and  hemorrhoids.  It  is  usually  a  neuritis  and  the  nerve  has  been 
found  thickened  at  the  point  where  it  crosses  the  pelvic  brim.  ■ 
1  '-Centralbl.  f.  GjTiak.,"  No.  25.   1901. 


l£f::x't^>^:;^L. 


Diagram  showing  Relations  and  Distribu: 


.,,..,,. ri„.:,  .rri...,i: 


Plate  II. 


7; /^™<.  «/■•/■/.«,/. 


,;.„. ,:.-.    ...V  \„1J, 


;  OF  Lumbar  and  Sacral  xnekves  (Flower^ 


LESIONS  OF  SPECIAL  SPINAL  NERVES. 


297 


The  obturator  nerve  has  the  same  origui  as  the  anterior  crural  and 
supplier  mainly  the  adductors  of  the  thigh  and  the  hip-  and  knee-joints. 
Its  paralysis  interferes  with  movements  that  require  approximation  of 
the  knees  and  impairs  ontward  rotation  of  tlie  thigh  through  weakness 
of  the  pectineus  and  external  obturator.  There  is  wasting  on  the  inner 
aspect  of  the  thigh.  The  sensory  disturbance  is  confined  to  the  hip-  and 
knee-joints,  which  may  also  display  trophic  disturbance.  The  knee  pain 
in  morbus  coxae  is  a  familiar  complaint  due  to  irritation  of  this  nerve. 

The  superior  gluteal  nerve  supplies  the  gluteus  medius  and  mini- 
mus and  tiie  tensor  yaginas  femoris.  Its  injury  interferes  with  ab- 
duction, outward  rotation,  and  circumduction  of  the  thigh. 

The  great  sciatic  nerve  is  diseased  singly  more  frequently  than  any 
other  nerve  in  tlif  lower  ex- 
tremity. Its  size  and  exposed 
position  within  the  pelvis,  at  the 
sciatic  notch,  and  behind  the  neck 
of  the  femur,  and  the  exposed 
position  of  its  branches,  notably 
the  external  popliteal  as  it  turns 
around  the  fibula  just  beloAy  the 
knee  and  the  plantar  branches  in 
the  sole  of  the  foot,  lay  it  especi- 
ally liable  to  accidents.  It  sup- 
plies the  flexors  of  the  knee, 
wdiicli  also  assist  in  maintaining 
extension  of  the  body  on  the  hip, 
and  all  the  muscles  below  the 
knee.  In  spite  of  its  size  and 
extensive  muscular  distribution, 
paralysis  of  the  sciatic  nerve  is 
not  so  disabling  as  that  of  the 
anterior  crural.  The  hip-joint 
can  be  fairly  controlled  by  the 
muscles  that  escape,  and  the  knee 
is  kept  in  extension  through  the 
anterior  crural.  The  whole  ex- 
tremity is  then  thrown  forward 
en  masse  and  used  as  a  peg-leg, 
as  in  the  hemiplegic  gait  (see 
p.  208). 

The    anesthesia    tliat    results 
from  palsy  of  the  great  sciatic 

occupies  a  narrow  strip  from  the  gluteal  fold  to  the  ham,  where  it  spreads, 
embracing  the  outer  side  of  the  leg  as  far  forward  as  the  tibial  crest,  and 
all  the  ankle  and  foot  except  on  the  inner  side.  The  wasting  is  marked 
on  the  back  of  the  thigh  and  below  the  knee  ;  the  limb  may  be  reduced 
to  the  last  degree.  Perforating  ulcers  on  the  sole  of  the  foot,  par- 
ticularly at  the  ball  of  the  great  toe,  are  likely  to  develop. 

The  external  division  of  the  sciatic,  the  external  pjopliteal  or  peroneal 
nerve,  occupies  an  exposed  position  (1)  in  the  ham  and  (2)  below  the 


Fig.  113. — Paralysis  of  anterior  crural ;  wasting  of 
right  thigh. 


298  DISEASES  OF  SPINAL  3IENINGES  AND  SPINAL  NERVES. 

knee  on  the  outside  of  the  neck  of  the  fibula.  It  supplies  the  extensors  of 
the  foot,  the  long  extensors  of  the  toes  and  the  peronei,  and  is  analogous  to 
the  lower  portion  of  the  musculospiral  in  the  arm.  Its  paralysis  causes 
foot-drop  and  toe-drop.  The  muscular  fullness  on  the  anterior  and  outer 
aspect  of  the  leg  is  lost;  the  uncovered  crest  of  the  tibia  is  extremely  prom- 
inent. A  tendency  to  equinovarus  is  produced  that  is  often  rendered  a 
permanent  deformity  by  contracture  in  the  calf-muscles.  The  outer 
half  of  the  front  of  the  leg  and  the  dorsum  of  the  foot  are  anesthetic. 

=The  inner  division  of  the  sciatic,  the  internal  popliteal,  is  analogous 
to  the  median  and  ulnar  in  the  upper  extremity.  It  supj)lies  all  the 
calf-muscles,  the  long  flexors  of  the  toes,  and  all  the  small  muscles  of 
the  foot  except  the  short  extensor  of  the  toes.  It  divides  into  the  in- 
ternal and  external  plantar  nerves,  which  are  sometimes  singly  diseased, 
^'hen  the  internal  plantar,  which  is  analogous  to  the  median,  is  alone 
divided,  we  have  j)aralysis  of  the  short  flexor  of  the  toes,  the  plantar 
muscles  of  the  great  toe  except  the  adductor,  and  the  two  inner  lum- 
bricales.  The  big  toe  becomes  overextended  at  the  first  joint  and  flexed 
at  the  second,  jwoducing  the  deformity  called  hammer-toe.  There  is 
anesthesia  on  the  inner  portion  of  the  plantar  surface,  embracing  also 
the  plantar  surface  of  three  and  a  half  toes. 

When  the  external  pjlantar,  the  analogue  of  the  ulnar,  is  divided,  the 
muscles  of  the  little  toe,  the  two  outer  lumbricales,  the  adductor  hallucis, 
and  all  the  interossei  are  paralyzed.  All  the  toes  assume  the  hammer- 
toe deformity,  and  the  use  of  the  foot  is  much  weakened.  Anesthesia 
is  produced  on  the  outer  half  of  the  sole  and  on  the  plantar  surface  of 
the  little  and  one-half  of  the  next  toe.  The  dorsal  surface  of  the  foot 
and  toes  is  supplied  by  the  musculocutaneous  and  anterior  tibial  nerves 
from  the  peroneal. 

When  the  internal  popliteal  is  divided  in  the  ham,  in  addition  to 
the  disability  due  to  paralysis  of  both  plantar  nerves  we  have  a  loss  of 
inward  rotation  of  the  flexed  leg,  due  to  paralysis  of  the  popliteus  muscle, 
and  loss  of  power  of  extending  the  foot  on  the  leg.  By  the  overaction 
of  the  anterior  leg-muscles  talipes  calcaneus  is  produced.  The  arch  of 
the  foot  at  the  same  time  becomes  exaggerated  ;  the  toes  are  extended  at 
the  first  and  flexed  at  the  other  joints,  j^roducing  the  analogue  of  the 
combined  ulnar  and  median  deformities  in  the  hand. 

Iletatarsalgia,  or  3Iorton's  disease,  probably  consists  of  a  pressure  neu- 
ritis or  neuralgia  of  some,  usually  one,  of  the  digital  branches  of  the 
plantar  nerves  between  the  heads  of  the  metatarsal  bones.  It  com- 
monly arises  from  the  use  of  too  narrow  boots,  and  can  be  remedied  in 
some  cases  by  a  shoe  of  proper  width  snugly  embracing  the  arch  of  the 
foot.  In  the  sole  a  depression  is  fashioned  to  relieve  pressure  on  the 
particular  painful  point.  Excision  of  the  metacarpal  head  or  neu- 
rectomy have  both  been  employed  successfully  in  severe  cases. 

Sciatic  Neuritis. — Xeuritic  and  neuralgic  conditions  have  been  so 
confused  under  the  term  sciatica  that  it  is  best  avoided.  Persistent  pain 
confined  to  the  region  of  the  great  sciatic  nerve  and  its  distribution,  Avith 
tenderness  in  the  nerve-trunk,  is  almost  always  due  to  neuritis.  Sciatic 
neuralgia,  on  the  other  hand,  is  a  rare  affection.  Inflammation  of  the 
sciatic  nerve,  from  its  clinical  importance,  demands  separate  consideration. 


LESIONS  OF  SPECIAL  SPINAL   NERVES.  299 

Causes. — The  causes  of  sciatic  neuritis  are  those  of  neuritis  else- 
where, and  may  be  divided  into  those  of  a  general  and  those  of  a  local 
sort.  In  the  first  group  we  may  name  adult  age,  as  sciatic  neuritis  is 
comparatively  rare  before  twenty-one.  Ilalea  are  much  more  commonly 
affected  than  females,  in  the  proportion  of  8  to  1,  according  to  Gibson,  i 
Gouty,  rheumatic,  and  neurotic  individuals  are  especially  liable  to  develop 
it.  Among  systemic  poisons  that  favor  its  occurrence  may  be  mentioned 
lead,  diabetes,  syphilis,  typhoid  fever,  malaria,  and  grip.  Pelvic  dis- 
ease and  pelvic  hyperemias  seem  also  active  in  causing  sciatic  neuritis, 
often  acting  also  as  local  causes  by  transmitting  pressure  or  inflammation 
to  the  sacral  plexus.  It  is  most  frequent  in  wet  and  cold  seasons  and 
among  those  whose  occupations  expose  them  to  wet  weather  or  extreme 
changes  of  temperature,  such  as  stokers,  puddlers,  and  laundresses.  It 
may  follow  operations  done  in  the  lithotomy  position. 

Amouff  the  numerous  local  causes  cold  is  usuallv  considered  most 
important.  Sitting  on  damp  ground  or  on  cold  stones,  standing  in  water, 
or  wearing  wet  clothing  or  shoes.  Compression  of  the  nerve  in  sitting 
or  by  vigorous  action  of  the  leg-flexors  and  rarely  contusions  from  blows 
below  the  sciatic  notch  may  induce  it.  Bony  thickening  at  the  notch  and 
syphilitic  deposits  at  this  site  have  occasioned  a  sciatic  neuritis.  In 
quite  a  proportion  of  cases  there  is  an  antecedent  lumbago.  The  down- 
ward extension  of  the  process  in  the  muscles  and  fascia  involves  the 
sciatic  nerve  at  the  notcli.  All  sorts  of  pelvic  tumors  and  even  constipa- 
tion are  capable  of  exercising  such  pressure  on  the  sacral  plexus  that  a 
sciatic  neuritis  follows.  The  nerve  is  sometimes  injured  in  this  position 
by  the  obstetrical  forceps  or  through  compression  by  the  gravid  uterus 
and/etoi  head.  Spinal  disease  and  new  growths  within  the  spinal  canal 
may  give  rise  to  neuritis  by  affecting  the  nerve-roots  in  the  cauda  equina 
or  at  the  vertebral  foramina.  Excessive  fatigue  of  the  legs,  as  in  the  use 
of  the  sewing-machine,  and  the  pressure  of  varices  in  the  extremity  or 
in  the  pelvis  or  about  the  nerve-trunk  may  occasion  it. 

Morbid  Anatomy. — From  rare  autopsies  and  occasional  operations 
the  condition  in  the  nerve  is  found  to  be  a  perineuritis,  affecting 
also  the  adventitia.  Secondarily  the  nerve-fibrils  suffer.  There 
is  often  an  increased  vascularity  and  redness  of  the  nerve,  and  vari- 
cose dilatations  in  and  about  the  nerve  have  been  observed  by  some. 
The  nerve  is  usually  edematous  and  tumefied.  In  a  word,  we  have  to 
deal  with  an  interstitial  neuritis.  It  is  usually  most  marked  at  the 
sciatic  notch  and  in  the  middle  of  the  thigh,  but  may  be  more  widely 
diffused.  A  similar  condition  is  sometimes  found  in  the  branches,  par- 
ticularly the  external  popliteal. 

Symptoras. — The  primal  symptoms  of  sciatic  neuritis  are  pain  and 
tenderness,  While  both  have  a  tendency  to  extend  throughout  the 
sciatic  territory,  at  first,  and  often  during  the  entire  case,  they  are  con- 
fined to  the  crural  portion  of  the  nerve  and  are  most  intense  below  the 
gluteal  fold  and  in  the  upper  half  of  the  thigh  directly  in  and  over  the 
nerve- trunk.      The  patient  will  often  trace  with  his  finger  the  seat  of 

1  "Laucet,"  London,  1893,  No.  3633. 


300  DISEASES  OF  SPINAL  MENINGES  AND  SPINAL  NERVES. 

pain  in  a  line  that  anatomically  corresponds  to  the  nerve  itself.  Below 
the  knee  the  pain  follows  by  preference  the  external  popliteal  nerve. 
The  pain  varies  in  degree,  but  is  persistent  in  character,  and  even  when 
slight  is  extremely  wearing  by  its  continuance.  It  is  notably  subject  to 
exacerbations,  which  are  quite  likely  to  occur  at  night  and  seriously  in- 
terfere with  sleeping.  AValking  or  any  vigorous  use  of  the  limb  is 
likely  to  increase  the  pain  at  once.  Even  after  many  hours  of  freedom 
from  it,  the  pain  may  sometimes  be  promptly  reestablished  by  taking  a 
few^  steps.  In  bed  the  jjatient  holds  the  limb  by  preference  in  a  semi- 
flexed position  at  the  hip  and  knee  with  the  ankle  extended.  This 
obviates  compression  of  the  nerve  by  the  muscles  and  avoids  stretching 
the  nerve  by  extension.  If  the  nerve  is  stretched  over  the  femoral 
neck,  bv  extending  the  knee  and  flexing  the  thigh  on  the  pelvis,  pain  is  at 
once  produced.  These  conditions  give  rise  to  a  characteristic  aititude 
and  gait  The  patient  holds  the  knee  semiflexed  and  inclines  the  body 
to  the  opposite  side,  throwing  into  prominence  the  hip  on  the  side  of  the 
sciatic  neuritis.  This  tends  to  keep  the  weight  on  the  sound  limb,  but 
its  long  continuance  may  develop  a  well-marked  scoliosis  with  the  lum- 
bar spine  convex  to  the  neuritis  and  a  compensatory  dorsal  curvature 
convex  to  the  sound  side.  After  recovery  from  the  neuritis  this  sciatic 
scoliosis  usually  disappears.  The  scoliosis  occurs  in  the  opposite  sense  in 
cases  marked  by  spasms  in  the  aflPected  leg  and  thigh,  which  are  due  to 
involvement  of  the  sacral  plexus  or  the  lumbar  cord,  and  manifest  espe- 
cially in  the  distribution  of  the  anterior  crural  nerve.  The  hip  on  the  side 
of  the  neuritis  is  then  approximated  to  the  lower  ribs,  the  opposite  one 
made  prominent ;  the  lumbar  curve  is  concave,  the  dorsal  curve  convex, 
on  the  side  of  the  disease.  This  homologous  sciatic  scoliosis  is  likely  to 
be  permanent  inasmuch  as  the  condition  upon  which  it  develops  is  a 
chronic  one  and  contractures  develop  to  fix  the  deformity.  In  walking 
there  is  an  evident  intention  to  use  the  diseased  limb  as  little  as  possible 
in  order  to  avoid  tension  and  muscular  compression  of  the  inflamed 
nerve. 

Pressure  made  with  the  fingers  along  the  trunk  of  the  nerve  and  its 
branches  develops  tenderness,  which  is  greatest  in  certain  regions. 
These  correspond  to  the  tender  points  of  Valleix.  The  most  constant 
are  the  following  :  The  ghdeal  point  over  the  sciatic  notch,  the 
trochanteric  point  above  the  trochanter  major,  a  tract  corresponding 
to  the  nerve-trunk  on  the  posterior  aspect  of  the  thigh,  a  pojjliteal  point 
in  the  ham  at  the  division  of  the  nerve,  a  jibidor  point  where  the  exter- 
nal popliteal  is  superficial  to  the  neck  of  the  fibula,  and  a  point  on  the 
dorsum  of  the  foot.  Less  frequently  we  find  lumbar  points  just  above 
the  sacrum,'  an  iliac  point  at  the  middle  of  the  iliac  crest,  a  pcdellar  point 
over  the  knee-cap,  points  in  the  calf,  points  behind  the  malleoli,  and 
plantar  points  in  the  sole  of  the  foot. 

It  is  at  these  points  that  the  patient  complains  of  the  paroxysms  of 
pain  that  commonly  mark  the  course  of  the  disease.  They  are  often  of 
a  lancinating,  boring,  tearing,  burning  character  that  racks  the  patient  and 
exceeds  his  powder  of  description  and  endurance.  They  are  usually  pro- 
voked by  use  of  the  member,  by  an  exposure  to  cold,  or  by  some  manip- 


LESIONS  OF  SPECIAL   SPINAL   NERVES. 


301 


ulation  of  the  parts,  but  may  come  on  spontaneously  and  even  periodi- 
cally, as  in  malaria.  They  often  follow  sleep,  probably  from  pressure 
or  a  continued  cramped  position. 

Cutaneous  sensibUitii  is  often  modified.  Hyperesthesia  in  the  sciatic 
area  is  the  rule  at  first,  but  in  prolonged  or  severe  cases  gives  place  to 
anesthesia.  Often  the  hypersensory  disturbance  is  confined  to  small 
areas  which  correspond  fairly  well  to  the  painful  points  previously  indi- 
cated. A^arious  paresthesias  are  encountered,  such  as  a  feeling  of  cold, 
heat,  prickling,  fullness,  formication,  etc. 

Motor  disturbances  are  less  constant  and  present  much  variation.  They 
usually  only  appear  in  the  graver  cases.  Sometimes  the  member  is 
shaken  in  a  spasmodic  manner  during 
the  painful  paroxysms,  and  painful 
cramps  in  the  calf-muscles  may  ag- 
gravate the  patient^s  suffering.  Re- 
flexes:  The  knee-jerk  is  rarely  ex- 
afffferated,  usuallv  it  is  diminished, 
and  the  Achilles  tendon  reflex  is  al- 
most always  greatly  reduced  or  absent. 
Gibson  1  notes  that  the  cremasteric 
reflex  is  usually  exaggerated  and  the 
plantar  may  be  increased,  but  the  toe- 
sign  of  Babinski  is  never  present.  If 
the  muscles  waste,  fibrillar  twitching  is 
frequently  observed,  and  there  is  pare- 
sis or  paralysis.  In  the  rare  spasmodic 
cases  already  mentioned,  in  which  the 
plexus  or  cord  is  involved,  the  entire 
limb  may  be  drawn  up  in  a  painful  and 
protracted  spasm  upon  the  slightest 
cutaneous  irritation,  even  by  a  breath 
of  air  or  the  contact  of  clothing. 

Involvement  of  the  vasomotor  and 
trophic  functions  of  the  nerve  in  se- 
vere and  protracted  cases  renders  the 
limb  livid  in  color,  cold  to  the  touch, 
with  a  temperature  reduced  several 
degrees.  The  perspiration  is  usually 
reduced,  but  may  be  increased,  and  the 

dermal  structures  frequently  suffer,  as  in  neuritis  elsewhere.  Scaliness, 
herpetiform  eruptions,  erythema,  and  acne  sometimes  appear,  and  perfo- 
rating ulcer  has  been  encountered.  The  muscles  waste  and  show  the 
reaction  of  degeneration  to  electricity.  The  wasting  is  most  noticeable 
in  the  leg  and  buttock.  The  enlarged  nerve  may  sometimes  be  felt. 
An  increase  of  cutaneous  fat  may  mask  the  muscular  wasting. 

A  double  sciatic  neuritis  is  almost  invariably  due  to  spinal  disease  or 
pelvic  disorder,  to  the  suspicion  of  which  it  should  always  give  rise. 

Diagnosis. — The  diagnosis  of  a  sciatic  neuritis  is  not  ordinarily  diffi- 
cult.    It  is  based  on  persistent  pain  and  upon  the  presence  of  the  ana- 
1  "Edin.  Med.  Jour.,"  No.  9,  1901. 


Fig.  114. — Sciatica  of  long  duration  on 
right  side;  wasting  of  biittoclv  and  leg,  some 
contiaetine  with  tendency  to  stand  on  toe, 
elevation  of  hip,  and  scoliosis 


302         DISEASES  OF  SPIXAL  MEXIXGES  AXD  SPIXAL  XEHVES. 

tomieally  located  tenderness,  ]S^euralgia  gives  rise  to  fleeting  pain 
without  tenderness  or  with  relatively  very  slight  tenderness,  but  early 
in  neuritis  this  combination  may  also  obtain.  Disease  of  the  hip-joint 
is  sometimes  mistaken  for  sciatic  neuritis.  Here  joint  tenderness  and 
fixation  and  the  location  of  the  pain,  which  does  not  correspond  to  the 
sciatic  but  to  the  obturator  nerve,  serve  to  differentiate  the  articular 
disease.  Hysteria  sometimes  mimics  sciatic  neuritis.  The  onset  of 
the  disorder  under  emotional  stress,  the  absence  of  trophic  disturbance, 
and  the  presence  of  contractures  and  other  stigmata  of  the  neurosis  dis- 
tinguish it.  When  the  neuritis  has  resulted  in  wasted  muscles,  cutane- 
ous eruptions,  etc.,  it  can  hardly  fail  of  recognition. 

More  difficult  questions  are  those  of  the  causation  and  location  of  the 
primal  inflammation.  In  every  instance  a  thorough  investigation  should 
be  made  of  the  pelvic  organs  and  the  spinal  functions.  If  the  neuritis 
is  bilateral,  the  disease  is  almost  surely  above  the  sciatic  notch.  In 
tabes  sciatic  pains  are  very  frequent,  but  their  lancinating  character 
and  appearance  in  storms,  with  other  symptoms  and  signs  of  the 
disease,  should  lead  to  their  proper  classification.  By  the  injection 
of  cocain  into  or  close  to  the  nerve  at  the  sciatic  notch  the  neuritic 
pain  is  inhibited,  unless  the  trouble  is  higher  up,  and  this  measure,  there- 
fore, helps  to  locate  it  Avithin  or  outside  the  pelvis.  A  histoiy  of  syph- 
ilis, malaria,  or  climatic  exposure  sometimes  tells  the  whole  story. 

Prog-nosis. — A  pure  sciatic  neuritis  is  of  good  ultimate  prognosis. 
If,  however,  it  be  due  to  pelvic  or  spinal  disease,  the  outlook  is  modi- 
fied for  the  worse  by  such  conditions  and  in  proportion  to  their  gravity. 
As  in  any-  other  neuritis,  the  probable  duration  must  be  estimated  from 
the  degree  of  severity  of  the  neuritic  process.  The  manageability  of 
the  patient  has  much  to  do  with  the  prospects  of  a  given  case,  as  a 
great  deal  depends  upon  rest,  and  preferably  rest  in  bed.  Usually  the 
disease  lasts  several  months,  and  under  conditions  of  use  and  irritation 
may  extend  over  years  or  present  nimierous  relapses.  If  nerve  degen- 
eration and  muscular  atrojjhy  develop,  from  six  to  nine  months  will  be 
required  for  recovery,  though  the  pain  may  subside  much  sooner. 

Treatment. — The  general  plan  of  treatment  of  a  sciatic  neuritis 
corresponds  to  that  of  any  ordinary  neuritis  (p.  282),  but  certain  local 
conditions  require  special  attention.  First  of  all  and  most  important 
in  the  early  stage  is  complete  rest  of  the  limb  by  absolute  rest 
in  bed.  This  can  be  rendered  the  more  effective  by  the  use  of 
a  long,  well-padded  splint,  extending  from  the  armpit  to  below 
the  foot,  where  a  cross-piece  on  the  surface  of  the  bed  serves  to 
maintain  a  proper  position  of  the  whole.  To  this  splint  the  limb 
should  be  lightly  secured  in  a  comfortable  position,  slightly  flexed 
at  the  hip  and  knee.  The  upper  end  of  the  splint  is  secured  to 
the  chest  by  webbing  bands  or  a  binder.  Care  must  be  taken  not  to 
constrict  the  limb  at  any  point.  Gouty,  rheumatic,  and  other  favor- 
ing conditions  require  appropriate  attention,  and,  of  course,  pelvic 
and  intestinal  trouble  must  be  properly  treated.  From  the  very  first, 
counterirritation  over  the  nerve-trunk  should  be  employed.  This  may  be 
in  the  form  of  sinapisms,  small  blisters,  or  preferably  by  the  Paquelin 
cautery.    Continuous  use  of  hot  poultices  or  the  ice-bag  is  to  be  advised. 


LESIONS  OF  SPECIAL  SPINAL  NERVES.  303 

Internal  medication  is  practically  useless,  though  some  favor  mercury, 
others  salicylates,  and  lately  nitroglycerin,  in  yi-g-grain  doses  every 
two  or  three  hours,  has  been  lauded.  In  the  writer's  experience  it  has 
had  no  value.  Acupuncture  over  the  course  of  the  nerve  serves  the  same 
purpose  as  any  other  form  of  counterirritation,  and  the  same  is  true  of 
injections  of  ether  and  other  fluids.  Gibson  ^  advises  puncturing  the 
nerve-trunk  itself  with  a  good-sized  needle  in  about  five  places,  and 
reports,  in  100  consecutive  cases,  56  cured,  32  much  improved,  10  im- 
proved, and  2  unimproved.  The  purpose  of  the  nerve-puncture  is  to  re- 
lieve the  supposed  edema  within  the  sheath.  The  usefulness  of  the  meas- 
ure is,  therefore,  limited  to  early  cases.  For  the  same  reason  the  needle 
should  be  used  at  the  point  of  involvement,  which  is  usually  opposite  the  glu- 
teal fold.  When  the  nerve  is  thus  pierced,  a  pain  darts  down  its  course. 
The  needle  is  to  be  inserted  at  intervals  of  about  an  inch  in  the  course 
of  the  nerve  in  the  thigh,  five  times  at  a  sitting,  and  repeated  after  two 
or  three  days.  Negro  ^  reports  113  rebellious  cases  in  which  vigorous 
pressure  over  the  nerve  at  the  most  painful  part  resulted  in  recovery. 
He  places  the  patient  on  his  face  and  with  all  his  force  presses  both 
thumbs  upon  the  nerve,  rolling  it  from  side  to  side,  for  fifteen  seconds. 
This  is  repeated  after  twenty  minutes  and  it  is  then  much  less  painful 
than  at  first.  The  patient  is  relieved  of  pain  for  several  hours  and  is 
enabled  to  walk.  It  is  recommended  that  this  manipulation  be  done 
about  six  times  at  two-hour  intervals  every  second  or  third  day.  This 
procedure  would  seem  better  calculated  to  cause  than  to  cure  a  neuritis, 
but  is  certainly  valuable.  Vigorous  massage  of  the  nerve  in  early  cases 
has  always  seemed,  in  the  writer's  experience,  to  increase  the  pain  and 
intensify  the  trouble,  but  in  late  cases  is  of  great  benefit,  particularly  in 
building  up  the  wasted  muscles.  Electricity  is  also  extensively  used  by 
some.  When  the  inflammation  is  recent  and  the  pain  severe  a  majority 
favor  a  broad,  positive  sponge-electrode  over  the  nerve,  w^ith  sufficient 
unbroken  current  to  redden  the  skin.  In  old  cases  the  vigorous 
faradization  of  the  thigh-  and  leg-muscles,  though  painful,  sometimes 
seems  to  be  of  benefit,  perhaps  by  the  mechanical  muscular  pressure  thus 
induced.  Stretching  the  sciatic  over  the  neck  of  the  femur  by  forcibly  flex- 
ing the  hip-joint  witli  the  knee  fully  extended  is  also  useful  in  late  stages. 

In  most  cases  sedatives  are  required.  Morphin  is  the  only  certain 
anodyne,  but  its  disadvantages  in  the  face  of  a  protracted  disease  should 
postpone  its  use  to  the  last  moment.  The  coal-tar  derivatives  have  some 
efiect,  and  cocain,  yL  of  a  grain  injected  near  the  nerve,  acts  very  well. 
The  best  results  will  probably  follow  complete  rest  and  vigorous  counter- 
irritation  in  the  early  stage  ;  active  massage,  cutaneous  stimulation,  and 
free  use  of  the  limb  in  protracted  cases. 

Various  springs  and  watering  places  have  gained  a  reputation  in  the 
treatment  of  sciatic  neuritis.  All  furnish  hot  baths  and  much  rubbing 
or  rude  massage.  The  enforced  idleness,  abundant  excretions  due  to 
drinking  the  water,  frequent  baths,  and  manipulations  are  the  factors  of 
their  success.      In  early  cases  such  a  course  is  often  clearly  detrimental. 

1  "Lancet,"  London,  1893,  No.  3633. 

2  "Bulletin  Med.  de  Paris,"  Jan.  22,  1896. 


304  DISEASES  OF  SPINAL  3IENINGES  AND  SPINAL  NERVES. 


CHAPTER  IV. 
MULTIPLE  NEURITIS. 

Under  the  terms  multiple  neuritis,  multiple  peripheral  neuritis,  poly- 
neuritis, beri-heri,  kakke,  etc.,  are  embraced  a  number  of  conditions 
which  have  groups  of  symptoms  mainly  referable  to  disturbed  functions 
of  the  peripheral  nerves.  The  old-time  distinction  between  central  and 
peripheral  organs  and  the  clinical  features  of  these  cases  directed  atten- 
tion mainly  to  the  nerve-trunks  and  endings.  In  view  of  our  present 
knowledge  of  the  neuron  unit,  supported  by  numerous  observations 
showing  spinal  nuclear  involvement  and  even  cerebral  cortical  disturb- 
ance in  multij^le  neuritis,  the  term  peripheral  must  be  dropped.  By 
multiple  neuritis  or  polyneuritis  is  here  meant  a  malady  in  which  the 
anatomical  lesions  open  to  our  present  means  of  investigation  are  usually 
more  pronounced  in  the  nerves  than  in  the  central  organs,  and  commonly 
consist  of  degeneration  of  the  axis-cylinder  process.  Cases  in  which 
no  histological  change  is  found  can  not  always  be  excluded,  as  many  of 
the  numerous  poisons  giving  rise  to  the  disease  may,  so  far  as  we  can 
detect,  sometimes  produce  dynamic  modifications  alone.  It  is  also 
allowable  to  suppose  that  the  early  effects  of  such  poisons  are  perturba- 
tive  of  nerve-cell  activity,  to  which  the  degeneration  in  the  distant  axis- 
cylinder  process  is  secondary,  and  that  if  the  poisoning  be  slight  in 
degree,  or  the  investigation  be  made  before  the  secondary  results  are 
developed,  no  change  whatever  will  be  presented.  Finer  methods,  how- 
ever, are  daily  displacing  post-mortem  appearances  which  were  formerly 
considered  normal,  and  the  dynamic  cases  are  being  steadily  brought 
within  the  domain  of  the  morphologically  abnormal.  It  is  likely  that 
polyneuritis  were  better  classed  as  a  general  disease  of  the  nervous 
system.  The  preponderance  of  neuritic  conditions  has  dictated  its  de- 
scription in  this  connection. 

Etiology. — Polyneuritis  is  the  result  of  a  systemic  poisoning  or  of 
conditions  which  entail  depraved  nutrition,  such  as  pernicious  anemia,  or 
of  both.  The  toxic  substances  which  are  capable  of  producing  a  multiple 
neuritis  are  most  commonly  alcohol  and  lead  ;  less  frequently  arsenic, 
mercury,  silver,  phosphorus,  sulphid  of  carbon,  oxid  of  carbon,  and 
ergot.  In  Manchester,  England,  an  epidemic  of  multiple  neuritis  was 
traced  to  arsenic  in  the  beer.  ^  Certain  autotoxic  substances  may  be  de- 
veloped that  have  the  same  pathogenic  power,  as  in  diabetes,  nephritis, 
and  intestinal  disturbance. 

The  infections  furnish  another  group  of  causative  agents.  Most  of 
the  infectious  fevers — typhoid,  typhus,  the  exanthemata,  erysipelas,  puer- 
peral infection,  acute  rheumatism,  influenza,  and,  above  all,  diphtheria — 
are  occasionally  followed  by  a  multiple  neuritis,  which  usually  appears 
during  convalescence.  In  rare  instances  the  neuritic  disturbance  appears 
1  J.  S.  Bury,  "Br.  Med.  Jour.,"  Dec.  1,  1900. 


MULTIPLE  NEURITIS.  305 

early  in  these  infectious  diseases,  and  again  rarely  it  may  follow  them 
after  a  considerable  period  of  time,  even  after  several  months  have  in- 
ters'ened. 

Syphilis  and  tuberculosis  have  both  been  cited  as  causal  of  poly- 
neuritis. Undoubtedly  they  both  predispose  to  it  by  the  systemic  de- 
pression they  occasion,  and  both  are  capable  of  producing  a  local  neuritis 
by  their  specific  proliferations.  The  anesthetic  form  of  leprosy  is  fre- 
quently marked  by  a  polyneuritis  which  is  actually  a  peripheral  disease 
and  due  to  the  invasion  of  the  nerve-trunks  by  the  bacillus  leprae. 
Malaria  can  undoubtedly  produce  it.  Eisenlohr,  in  Homburg,  and 
Graeme  Hammond,  in  Connecticut,  have  reported  small  epidemics  of  the 
disease,  which  also  in  the  form  of  beri-beri  is  common  in  certain  parts  of 
Asia,  South  America,  and  on  shipboard  during  long  voyages. 

Cachexias  of  all  sorts,  but  especially  those  associated  with  cancer, 
are  likely  to  develop  polyneuritis  ;  usually,  however,  combined  with 
changes  in  the  spinal  cord.  Old  age,  and  especially  old  age  marked 
by  extreme  arteriosclerosis  and  atheroma,  may  be  the  occasion  of  the 
disease  by  failure  of  nutrition  both  in  the  trophic  spinal  apparatus 
and  in  the  peripheral  nerve-trunks.  Multiple  neuritis  occurs  infre- 
quently before  adult  age.  In  children  it  is  usually  due  to  infection, 
especially  diphtheria,  measles,  and  influenza.  Much  more  rarely  it  is 
<;aused  in  childhood  by  lead  or  arsenic.  Arsenic  has  caused  poly- 
neuritis in  some  cases  of  chorea  where  it  has  been  too  freely  used. 
After  adult  age  is  reached  all  forms  are  comparatively  common. 
Alcoholic  polyneuritis  is  most  frequent  between  thirty  and  forty.  The 
senile  and  atheromatous  forms  appear  only  after  sixty,  ^yomen  fur- 
nish the  greater  proportion  of  alcoholic  cases  ;  men,  of  the  rheumatic  and 
toxemic  variety.  Occupation  plays  a  large  part.  Painters,  plumbers, 
type-setters,  rubber-workers,  match-factory  employees  and  employees  in 
white-lead  factories,  and  lead-miners  are  especially  exposed.  Various 
other  pursuits  requiring  the  use  of  lead,  arsenic,  and  mercury,  or  the 
handling  of  spirituous  liquors,  the  last  by  indulgence,  furnish  many 
cases.  A'^ery  often  more  than  one  cause  is  operative,  as  when  tubercu- 
losis leads  to  constant  alcoholic  stimulation,  or  the  onset  of  physical  or 
mental  depression  in  an  alcoholic  precipitates  the  attack  of  polyneuritis. 

Morbid  Anatomy. — Lesions  in  the  Nerves. — In  the  verv  great 
majority  of  cases  the  condition  found  in  the  nerve-trunk  is  one  of  degen- 
eration comparable  to  that  caused  by  traumatism,  with  the  diiference  that 
in  polyneuritis  the  nerves  show  many  axis-cylinders  in  a  comparatively 
normal  condition.  Indeed,  all  grades  of  Wallerian  degeneration  may  be 
encountered  in  a  single  nerve,  the  fibers  being  differently  affected  by 
the  toxic  agent.  It  is  also  evident  that  the  intensity  of  the  toxic  pro- 
cess and  the  duration  of  the  disease  will  produce  corres})onding  modifi- 
cations in  the  nutrition  of  the  axis-cylinder.  It  is  possible  that  event- 
ually we  will  be  able  to  distinguish  a  variation  in  the  degeneration 
produced  by  the  various  provocative  agents,  but  at  present  they  escape 
detection.  The  degeneration  following  lead-poisoning  is  apparently 
identical  with  that  caused  by  toxins.  The  intensity  of  the  neuritis 
generally  decreases  from  the  periphery  toward  the  centers.  Hyperemia 
of  the  endo-  and  perineurium  is  frequently  observable.  In  addition  to 
20 


306  DISEASES  OF  SPINAL  MENINGES  AND  SPINAL  NERVES. 

the  axis-cylinder  changes  in  some  cases,  usually  those  of  long  standing, 
there  is  an  increase  in  the  adventitia.  A  considerable  thickening  of  the 
nerve-trunk  results.  This  fibrous  proliferation  may  even  be  excessive  and 
at  exposed  points  sometimes  produces  nodular  enlargements.  Syphilitic, 
leprous,  and  tubercular  changes  incident  to  these  various  diseases  are  also 
encountered.  In  the  leprous  form  the  nerve  may  also  contain  the  char- 
acteristic bacilli.  Ceni,i  Ci'ocq,^  and  others,  by  inoculation  experiments 
in  lower  animals,  have  produced  the  same  changes  in  the  nerves  and  in 
the  spinal  cord  as  are  found  in  human  subjects,  but  not  in  the  brain. 

Lesions  of  the  Spinal  Cord.— In  a  considerable  and  constantly  grow- 
ing number  of  cases  the  cellular  parts  and  even  the  conduction  tracts  of 
the  spinal  cord  have  shown  involvement.  Oertel,  Dejerine,  and  Pernice 
have  described  lesions  of  the  anterior  horns  in  diphtheric  neuritis.  Many, 
among  them  Finlay,  Achard,  Schaeifer,  and  Larkin  and  Jelliife,^  have 
noted  the  same  thing  in  alcoholic  neuritis.  Others  again,  as  Thiersch 
and  Rosenbach,  recognize  a  simple  atrophy  of  the  cornual  cells  in  lead- 
palsy.  The  cells  of  Clarke's  column  and  the  fibers  of  the  posterior  and 
cerebellar  tracts  have  presented  diffuse  lesions  of  an  inflammatory  and 
degenerative  nature.  Henschen  *  records  a  case  of  typical  diphtheric 
polyneuritis  followed  by  acute  disseminate  sclerosis.  The  spinal  cellu- 
lar changes  consist  either  of  a  changed  crenelated  form  with  vacuola- 
tion,  or  of  changes  of  an  inflammatory  character,  sometimes  with 
hemorrhages.  The  lesions  of  the  spinal  white  matter  are  principally 
degenerative. 

JLesions  of  the  Brain. — Pernice  and  Scagliosi  ^  in  diphtheric  cases 
found  the  principal  changes  in  the  brain,  cerebellum,  and  cord,  and  re- 
ferred them  to  circulatory  disturbance  followed  by  degenerative  changes 
and  hemorrhage.  The  cortical  cells  showed  atrophic  degeneration, 
which,  as  in  the  cord,  especially  afi^ected  their  protoplasmic  prolonga- 
tions. The  well-known  effects  of  alcohol  and  lead  on  the  cerebrum  are 
also  found.  Dehio,^  experimenting  on  animals  with  poisonous  dose& 
of  alcohol,  found  by  appropriate  stains  that  many  of  the  cortical  cells  were 
changed  in  whole  or  in  part.  The  presence  of  psychical  symptoms  in 
many  cases  of  polyneuritis  abundantly  proves  that  the  affection  is  one 
that  does  not  spare  the  highest  nervous  apparatus. 

On  the  other  hand,  in  many  cases  of  polyneuritis  no  changes  have 
been  detected.  Thus  Hosche/  in  a  carefully  examined  case  of  wide- 
spread diphtheric  palsy,  found  absolutely  no  change,  even  in  the  muscles 
which  had  been  paralyzed.  He,  therefore,  attributes  the  symptoms  to 
toxins  which  operated  without  causing  anatomical  changes.  The  ojitic 
nerve,  which  is,  in  fact,  a  cerebral  structure,  is  often  affected  in  polyneur- 
itis. We  have  here  to  recall  the  whole  list  of  toxic  amblyopias. 
Alcohol  again  plays  the  most  frequent  part.  The  medulla  and  the 
cranial-nerve  nuclei  are  subject  to  the  same  changes  as  the  analogous 
portions  of  the  spinal  cord. 

Lesions  in  the  Muscles. — The  muscles  supplied  by  the  affected  nerves 

1  "Eif.  Med.,"  Feb.  5,  1896. 

2  "Rev.  Men.  desMal.de I'Enfance,"  Sept.,  1895.  ^  "Med.  Eec,"  July 8,  1899. 
*  ' '  Fortschritte  der  Medicin, ' '  1896.  *  < '  Rjf _  jyied. , ' '  Oct.  8,  1895, 
«  "  Centralblatt  f .  Nervenh.  u.  Psych.,"  March,  1895. 

'  "Miinch.  med.  Wochens.,"  March  12,  1895. 


MULTIPLE  NEURITIS.  307 

in  polyneuritis  undergo  changes  similar  to  those  in  simple  neuritis 
or  in  nerve-division,  but  usually  less  in  degree.  The  escape  of  numer- 
ous fibrils  in  the  nerve-trunks  is  probably  to  be  correlated  with  the  per- 
sistence of  numerous  apparently  normal  fibers  in  the  atrophied  muscles. 
Another  and  important  feature,  however,  is  added,  and  that  is  the  ten- 
dency to  fibrous  hyperplasia  in  the  affected  muscles,  constituting  in  well- 
marked  cases  an  interstitial  myositis,  which,  in  its  turn,  may  act  detriment- 
ally upon  the  sarcode  elements.  This  muscular  fibrosis  also  explains  in 
part  some  of  the  tendinous  contracture  deformities  of  late  cases.  The 
presumption  is  that  an  element  of  irritation  is  present  which  acts 
through  the  apparently  normal  nerve-fibrils,  though  Babinski  is  dis- 
posed to  attribute  it  to  the  pathogenic  effect  of  the  toxic  agent  directly 
on  the  muscle. 

Changes  in  the  trophic  and  sea^etory  functions  of  the  nerve  are,  like 
the  motor  and  sensory,  less  pronounced  than  in  a  simple  neuritis,  but 
do  appear,  and  are  marked  by  disappearance  of  the  fatty  panniculus, 
by  thinned  and  glossy  skin,  vascular  disturbances,  mottling,  edema, 
lack  of  perspiration,  and  by  modified  growth  of  hair,  nails,  and 
epithelium. 

Symptoms. — The  symptoms  arising  from  so  wide-spread  a  dis- 
ease are  correspondingly  varied.  It  is  necessary  to  take  them  up  sys- 
tematically, but  it  may  be  said,  once  for  all,  that  they  are  symmetrical,  as 
a  rule,  aflPecting  both  sides  of  the  body  in  a  similar  manner.  This  might 
be  expected  from  a  toxic  cause  of  systemic  distribution.  It  is,  how- 
ever, a  fact  that  the  symptoms  usually  commence  first  on  one  side  and 
frequently  are  slightly  more  marked  on  one  side  than  on  the  other 
throughout  the  disease.  They  may  be  alternately  exaggerated  on  the  two 
sides.  Some  toxic  agents,  as  lead,  affect  more  especially  the  upper  extrem- 
ities ;  others,  particularly  alcohol,  principally  involve  the  lower.  Again^ 
in  some  cases  the  motor  symptoms  predominate  ;  in  others,  the  sensory. 

Muscular  and  Motor  Symptoms. — TJie  Lower  Extremities. — The 
motor  disturbance  in  polyneuritis  is  principally  one  of  deficit,  a  paresis 
that  in  severe  cases  reaches  complete  paralysis.  It  is  most  marked  at 
the  distal  extremities  of  the  limbs,  and  in  the  great  majority  of  cases 
affects  first  and  most  the  extensor  muscles.  In  the  lower  extremity  the 
extensors  of  the  toes,  the  peroneal  muscles,  and  the  dorsal  flexors  of 
the  foot  are  the  ones  usually  most  implicated.  In  marked  cases  foot- 
drop  is  complete.  The  foot  falls  into  line  with  the  leg  and  the  plantar 
surfiice  turns  inward,  passively  producing  an  equinovarus  position  when 
the  patient  is  recumbent,  or  when  the  foot  is  raised  from  the  floor  (Figs. 
115  and  116).  In  milder  cases  the  patient  can  not  raise  the  toes  from  the 
floor  while  standing  on  the  heels,  or,  in  other  words,  can  not  dorsally 
flex  the  foot  beyond  a  right  angle.  The  toes  remain  in  a  flexed,  bunched 
position,  and  can  not  be  extended  or  separated.  Efforts  against  resist- 
ance at  once  disclose  the  weakness  of  these  muscles.  A  peculiar  and 
characteristic  gait  is  developed.  In  order  to  clear  the  ground  the  patient 
is  compelled  to  raise  the  foot  by  flexing  the  thigh.  The  leg  is  then 
thrown  forward  like  a  flail ;  the  toe  is  pendent ;  the  outer  border  of  the 
foot  is  depressed  and  brought  to  the  ground  toe  first,  or  in  a  flat-footed 


308 


DISEASES  OF  SPINAL  MENINGES  AND  SPINAL  NERVES. 


manner,  or  the  outer  border  of  the  foot  strikes  the  floor  first.  The 
other  foot  is  then  advanced  in  precisely  the  same  manner.  From  this 
high  knee-action  Charcot  denominated  the  gait  "  steppage."  The  dang- 
ling foot  sometimes  wears  the  boot  at  the  toe  and  frequently  scrapes  up 


Fig.  115. — Drop-foot  and  deformities  in  alcoholic  multiple  neuritis. 

the  dirt  of  the  pavement.  In  very  rare  instances  a  contrary  position 
of  the  foot  and  an  opposite  sort  of  gait  has  been  produced  by  loss  of 
power    in    the   calf-muscles,  the    anterior    group  being  spared.       The 


Fig.  116. — Gait  in  multiple  neuritis,  showing  the  high  knee-action  and  the  dangling  foot  descending  by 

its  toe  and  outer  border. 


patient  in  such  cases  in  walking  brings  the  heel  first   to  the  ground 
with  the  foot  inverted  and  dorsally  flexed. 

When  the  thigh-extensors  are  also  affected  and  the  muscles  at  the  root 
of  the  limb  are  weakened,  the  use  of  the   member  becomes  well-nigh 


MULTIPLE  NEURITIS.  309 

impossible.  A  paresis  of  the  extensors  of  the  knee  is  often  associated 
with  that  of  the  leg  muscles  in  alcoholic  polyneuritis.  As  above  indicated, 
the  loss  of  power  may  be  trifling  or  absolute.  While  the  muscle-groups 
enumerated  are  most  affected,  their  opponents  also  lose  power,  but  in 
less  degree.  The  loss  of  synergy  alone  would  account  for  much  of 
their  weakness,  but  the  neuritic  process  does  not  entirely  spare  them,  and 
in  severe  cases  of  long  standing  they  also  waste. 

The  Upper  Extremities. — The  distal  segments  of  the  upper  ex- 
tremities, as  in  the  lower  limbs,  are  principally  involved.  The  muscles 
of  the  forearms  and  hands  are  most  affected.  In  polyneuritis  the  mus- 
cles under  the  control  of  the  musculospiral  are  usually  the  first  to  suffer, 
the  most  involved,  and  the  last  to  recover.  Drop-wrist,  the  attitude 
characteristic  of  musculospiral  palsy  (see  p.  289),  is,  therefore,  a  promi- 
nent deformity,  and  the  disability  of  the  hand  conforms  to  this  type,  but 
the  supinator  longus  often  escapes.  In  some  instances,  to  the  drop-wrist 
is  added  the  deformity  characteristic  of  a  median-nerve  palsy,  and  the 
claw-hand  or  ape-hand  is  developed.  The  postcarpal  tumor  may  also 
appear.  In  still  rarer  cases  the  deltoid,  biceps,  long  supinator,  spinati,, 
and  short  supinator  first  suffer,  but  ordinarily  they  are  involved,  if 
affected  at  all,  after  the  forearm-  and  hand-muscles  have  been  in- 
vaded. These  functional  groupings  of  the  palsies  of  polyneuritis  again 
furnish  us  with  evidence  of  the  essentially  nuclear  character  of  the 
lesion. 

The  trunk-muscles  are  sometimes  also  weakened,  but  only  after  the 
paresis  of  the  extremities  has  become  pronounced.  Standing,  walking, 
and  even  sitting  may  thereby  be  enfeebled  or  completely  prevented. 

The  muscles  of  the  nech  and  face  in  very  severe  and  extensive  cases 
may  also  be  affected,  as  may  the  muscles  of  the  eyes,  tongue,  throaty 
larynx,  diaphragm,,  of  respiration,  and  of  the  heart  itself.  Involvement 
of  the  muscles  of  the  throat,  palate,  and  accommodative  visual  appa- 
ratus is  a  characteristic  combination  in  diphtheric  palsy.  Brunton  ^ 
calls  attention  to  a  mask-like  face,  frequently  seen  in  the  alcoholic 
variety  of  multiple  neuritis,  affecting  particularly  the  portion  of  the  face 
between  the  eyes  and  lips.  He  also  contends  that  the  pupillary  response 
for  accommodation  is  lost,  that  for  light  remaining  active,  the  converse 
of  the  Argyll-Robertson  phenomenon. 

Electrical  Changes. — Owing,  probably,  to  the  variable  amount  of  in- 
jury and  irritation  in  the  nerves,  electrical  tests  in  polyneuritis  give  all 
possible  changes  from  the  normal  in  different  cases,  and  frequently  at 
different  periods  in  the  same  case.  Not  infrequently  in  the  early  days 
of  the  disease  electrical  excitability  to  faradic  and  galvanic  currents  is 
somewhat  increased.  This  lasts  but  a  short  time,  when  diminished 
faradic  response  is  presented,  and  may  be  attended  in  rare  instances  by 
voltaic  diminution,  a  purely  quantitative  change.  More  frequently  and 
customarily,  as  faradic  excitability  diminishes,  the  voltaic  current  aug- 
ments in  power  and  eventually  presents  some  or  all  of  the  items  of  the 
reaction  of  degeneration  (see  p.  47).  Complete  abolition  of  electrical 
response  to  the  galvanic  current  is,  however,  rare,  even  in  the  severest 
1  "Br.  Med.  Jour.,"  Dec.  1,  1900. 


310  DISEASES  OF  SPINAL  3IENINGES  AND  SPINAL  NERVES. 

cases.  Popoff  ^  contends  that  diminution  of  electrical  responses  may  be 
detected  long  before  paresthesia  is  noticed.  Erb  has  noticed  that  with 
the  increased  voltaic  responses  sometimes  myoidema  can  be  easily  pro- 
duced. A  sharp  blow  across  the  muscles  with  the  handle  of  a  percus- 
sion hammer,  especially  near  the  tendinous  portions,  produces  localized 
contraction  of  the  muscle-fibers,  causing  a  swelling  that  lasts  for  several 
minutes. 

Muscular  atrophy  follows  the  muscular  enfeeblement,  which  in  its 
turn  is  usually  preceded  by  sensory  disturbances.  The  muscular  tone 
sinks  as  the  paralytic  features  develop  and  amyotrophia  is  promptly  added. 
In  rare  cases  the  loss  of  power  is  pronounced  and  yet  the  muscular 
masses  retain  their  usual  conformation  and  electrical  responses,  but 
gradually  their  swelling  curves  are  replaced  by  straight  lines  or  even  by 
hollows,  and  the  wasting  in  extreme  cases  denudes  the  bones  of  every- 
thing but  the  dermal  and  fibrous  structures.  A  polyneuritis  may  stop 
at  any  point  or  attain  any  degree  of  intensity.  The  muscular  atrophy 
necessarily  shows  corresponding  variations.  As  the  paralytic  features 
preponderate  in  the  extremities  and  particularly  in  the  distal  portion  of 
the  limbs,  the  amyotrophia  is  most  marked  in  the  same  positions.  We, 
therefore,  find  it  ordinarily  in  the  hands  and  feet,  in  the  forearm  and 
below  the  knee,  but  there  is  no  voluntary  muscle  that  may  not  be  in- 
volved, and  even  the  internal  viscera  are  not  immune.  In  some  cases 
a  thick  layer  of  subcutaneous  fat  or  an  edematous  condition  may  dis- 
guise the  wasting  of  the  muscles. 

Other  Ifotor  Disturbances. — The  lack  of  muscular  balance  in  some 
cases  and  the  diminution  of  muscular  strength,  whenever  pronounced, 
may  be  attended  by  a  certain  amount  of  coarse  tremhling,  which  is  likely 
to  appear  on  voluntary  eifort  or  when  the  muscles  are  strongly  exerted. 
This,  taken  with  the  disturbed  sensation,  especially  in  the  fingers,  leads 
to  much  clumsiness  in  the  smaller  co5rdinate  movements  of  the  hand. 
Most  patients  early  find  difficulty  in  picking  up  small  objects,  buttoning 
their  clothing,  etc.  For  similar  reasons  they  are  not  so  precise  in  the 
use  of  the  lower  extremities,  and  from  the  loss  of  sensation  in  the  feet 
they  sway  and  sometimes  fall  in  attempting  to  stand  with  closed  eyes. 
The  gait  may  also  appear  ataxic,  but  in  the  sitting  or  recumbent  posi- 
tion these  patients  direct  the  movements  of  their  lower  extremities  with 
as  much  exactness  as  their  limited  power  will  allow.  The  same  is  true 
for  the  movements  of  the  upper  limbs.  The  apparent  ataxia  must  usu- 
ally be  attributed  to  muscular  weakness.  Fibrillary  twitching  in  the 
atrophic  muscles  is  frequently  seen.  Cramps  sometimes  occur  upon 
effort  being  made  after  a  period  of  repose,  or  spontaneously,  or  after 
the  use  of  a  comparatively  mild  faradic  current.  Patients  very  fre- 
quently complain  of  cramps,  and  of  cramped  positions.  Hyperesthesia 
and  other  sensory  disorders  probably  lead  to  such  complaints. 

Contractures  are  very  prone  to  develop.      Their  disabling  character 
can  not  be  too  strongly  emphasized,  the  more  so  as  the  malposition  to 
which  they  give  rise  can  usually  be  prevented  by  proper,  early  manage- 
1  "Neurol.  CentralbL,"  1900. 


3TUL TIPLE  KEUEITIS.  311 

ment.  They  arise  :  (1)  In  ])art  from  the  lack  of  balance  in  the  muscles 
on  the  two  sides  of  the  limbs  ;  (2)  in  part  from  the  natural  tendency 
of  the  flexors  to  impose  upon  the  joints  a  position  of  demiflexion;  (3)  in 
part  from  the  action  of  gravity,  and  (4)  in  great  part  from  the  develop- 
ment of  the  muscular  fibrosis  and  fibrotendinous  retraction  in  the  mus- 
cles incident  to  the  disease.  From  these  causes  the  foot-drop  becomes 
a  fixture.  Attempts  to  dorsally  flex  the  ankle-joint  ai'e  stopped  abruptly 
by  the  rigid,  shortened  heel-tendon,  which  alone  impedes  the  joint's  move- 
ments. A  similar  condition  is  often  present  at  the  knee,  elbow,  wrist, 
and  even  at  the  hip  and  shoulder.  In  exceptional  cases  tenotomies  are 
eventually  required  to  enable  the  patient  to  put  the  heels  to  the  floor. 

The  Reflexes. — The  cutaneous  reflexes  in  the  parts  affected  by  a  poly- 
neuritis may  be  normal,  but  are  usually  diminished  in  activity  aud 
sometimes  abolished.  The  tendon  reflexes  are  almost  always  diminished 
or  abolished  in  the  limbs  that  are  most  affected,  but,  of  course,  only  in 
the  muscles  that  suffer.  The  Achilles  jerk  may  be  abolished  and  the 
knee-jerk  present,  or  there  may  be  some  difference  on  the  two  sides  of 
the  body.  In  well-marked  cases,  however,  the  ankle,  knee,  wrist,  and 
elbow  reflexes  are  usually  greatly  diminished  and  often  wanting.  Occa- 
sionally in  slight  cases,  and  then  usually  only  at  first,  the  reflexes  may 
be  very  active,  or  even  exaggerated,  but  clonus  is  never  encountered. 
The  organic  reflexes  governing  the  intestine  and  bladder  are  very  rarely 
impaired  and  practically  never  abolished.  Sphincteric  control  is,  there- 
fore, maintained. 

Sensory  Symptoms. — The  sensory  disturbances  of  polyneuritis  are 
usually  the  first  to  appear,  the  last  to  cease,  aud  they  often,  even  more 
than  the  paralytic  features,  distress  and  worry  the  patient.  Popoff/ 
however,  contends  that  reduced  faradic  reactions  are  the  earliest  symp- 
toms, and  the  author  has  foretold  multiple  neuritis  in  alcoholic  cases  by 
the  diminished  knee-jerks  weeks  before  there  was  any  complaint  of  pares- 
thesia. Most  cases  begin  by  paresthesia  in  the  extremities,  which  the 
patients  describe  by  such  words  as  tingling,  numbness,  dumbness,  pins 
and  needles,  coldness,  heat,  crawling,  tickling,  and  similar  expressions. 
They  shortly  notice  that  tactile  impressions  produce  abnormal  sensations, 
and  it  often  requires  careful  questioning  and  examination  to  determine 
whether  the  condition  is  one  of  hypersensitiveness,  blunted  sensitiveness, 
or  both  combined.  A  light  stroke  with  a  feather  may  give  rise  to  a  dis- 
tinct sensation  of  tingling,  when  the  patient  can  not  tell  whether  he  has  a 
small  object,  such  as  a  pin,  between  the  tips  of  his  fingers  and  thumb,  or 
may  not  be  able  to  recognize  such  a  familiar  object  by  the  sense  of  touch. 
As  a  rule,  these  sensory  disturbances  are  persistent  when  once  established, 
and  only  change  gradually  for  the  better  or  worse.  In  extent  they  present 
the  greatest  differences,  depending  upon  the  activity  of  the  neuritis  and 
its  du'^ation.  Commencing  usually  in  the  finger-tips  and  in  the  toes  and 
soles  of  the  feet,  they  gradually  extend  up  the  limbs,  enveloping  them 
as  if  they  were  submerged  in  some  loose  material  like  cotton  or  shavings. 
Commonly  the  disturbance  does  not  go  above  the  elbow  and  knees,  but 
may  reach  the  roots  of  the  limbs  and  invade  the  trunk.  In  a  number 
1  "Neurol.  Centralbl.,"  No.  13,  1900. 


312  DISEASES  OF  SPINAL  MENINGES  AND  SPINAL  NERVES. 

of  cases  similar  paresthesias  are  felt  in  the  face,  lips,  and  tongue  at  an 
early  stage  of  the  malady. 

As  the  disease  advances,  these  persistent  subjective  sensory  symp- 
toms become  aggravated  and  frequently  marked  by  crises  of  intense 
suffering,  which  are  usually  of  the  same  character  in  a  given  case,  but 
vary  widely  in  different  patients.  One  will  complain  of  the  most  intense 
pain  ;  another  suffers  with  burning  sensations  and  wants  cold  applied  ;  a 
third  feels  that  the  extremities  are  cold  to  freezing  and  in  a  warm  room 
bundles  them  with  woolens.  As  a  rule,  when  pain  or  sensory  suflFering 
is  pronounced  it  is  most  marked  in  the  lower  extremities.  It  often 
deprives  the  patient  of  sleep  and  is  an  exhausting  element  in  the  case. 

Sensibility  to  touch,  pressure,  painful  impressions,  and  temperature 
may  also  undergo  marked  changes,  which  are  infinitely  varied.  The 
cutaneous  sensations  are  disturbed  in  areas  roughly  corresponding  ,to  the 
paresthetic  distribution  and  the  motor  loss.  Early  in  these  cases,  when 
the  irritative  conditions  in  the  nerve  are  probably  at  their  maximum, 
there  is  a  tendency  to  hyperesthesia.  The  patients  may  complain  that  their 
stockings  feel  as  though  full  of  knots,  that  the  bedding  feels  as  if  made  of 
ropes,  and  in  various  phrases  express  the  exaggerated  modifications  of 
touch.  Light  contact  may  be  painful.  Pressure  on  the  nerve-trunks  and 
on  the  muscular  masses  usually  develops  marked  tenderness,  and  in  severe 
cases  may  evoke  a  painful  crisis.  In  many  marked  cases  some  dissocia- 
tion of  cutaneous  sensations  is  observed.  The  pain  and  temperature 
sensations  may  be  diminished  more  than  tactile  impressions,  or  touch 
may  be  abolished,  the  contact  giving  rise  to  pain  or  discomfort,  which 
may  not  be  properly  located.  In  cases  where  the  local  conditions  of 
wasting,  anesthesia,  and  electrical  tests  indicate  marked  nerve-degenera- 
tion, the  patient  may  still  complain  of  pains,  burning,  etc.  In  late  cases 
anesthetic  features  are  nearly  always  present,  but  it  is  rare  for  them  to 
reach  a  complete  degree.  Some  modifications  of  the  muscular  and  joint 
sense  are  also  encountered,  so  that  the  blindfolded  patient  may  have  un- 
certain knowledge  of  the  position  of  the  limbs.  The  transmission  of 
all  forms  of  cutaneous  sensation  may  be  retarded,  and  generally  all 
forms  are  uniformly  decreased. 

Various  toxic  substances  differ  in  the  sensory  disturbances  they  pro- 
duce. Some,  with  alcohol  and  grip  at  the  head,  produce  marked  painful 
disorders  of  sensation  ;  while  others,  of  which  lead  and  diphtheria  are 
the  chief,  mainly  cause  motor  impairment, — another  argument  for  the 
central  location  of  the  disturbing  element. 

Ocular  Symptoms. —  Vision. — Among  the  special  senses,  that  of 
vision  is  the  one  principally,  if  not  alone,  affected.  Many  of  the  sub- 
stances capable  of  producing  a  polyneuritis  also  engender  a  toxic 
amblyopia.  These  are  especially  alcohol,  lead,  arsenic,  and  the  carbon 
gases.  (For  the  special  symptoms  which  pertain  to  them,  reference 
should  be  made  to  p.  102,  and  to  special  works.)  It  must  be  borne 
in  mind  that  even  a  pronounced  optic  papillitis,  retracted  fields,  color 
scotomata,  and  considerably  reduced  vision  may  fail  to  attract  a  patient's 
attention  and  must  be  intelligently  sought.  In  the  toxic  cases  the  con- 
dition is  bilateral  and  symmetrical,  and  usually  of  insidious  development. 


MULTIPLE  NEURITIS.  313 

Motion. — Squints  and  diplopia  have  been  noted  as  frequently  as  once 
in  ten  times  in  diphtheric  neuritis  (Remak)  and  occur  also,  but  less 
frequently,  in  the  alcoholic  form.  They  are  due  usually  to  a  neuritis 
of  the  oculomotor  nerves,  but  sometimes  to  nuclear  involvement,  when 
they  are  commonly  attended  with  apoplectic  features  and  are  of  sudden 
onset.  The  motor  nerves  of  the  eyeball  may  be  affected  equally  or 
singly,  producing  corresponding  deviations,  ptosis,  etc.  Commonly 
single  muscles  are  paralyzed,  a  complete  ophthalmoplegia  being  usually 
of  nuclear  origin. 

The  Pupils. — In  rare  cases  of  polyneuritis  the  pupils  have  been 
affected.  r3ilatation,  contraction,  and  inequality  have  been  noted  by 
various  observers.  The  pupillary  reflexes,  however,  are  unimpaired, 
and  the  Argyll-Robertson  phenomenon  is  not  seen. 

Accommodation  is  often  disturbed  in  diphtheric  neuritis,  of  which 
it  is  one  of  the  most  constant  symptoms.  Here,  too,  the  pupils  remain 
active.  As  a  result  of  the  paralysis  of  accommodation  vision  for  near 
objects  is  reduced.  This  can  be  detected  even  in  very  young  children 
by  asking  them  to  note  a  pin-hole  in  a  calling  card.  For  older 
patients  printed  characters  are  blurred  and  illegible. 

Trophic  and  General  Conditions. — In  addition  to  the  muscular 
atrophy,  the  trophic  disturbance  is  manifest  in  the  extremities,  especially 
toward  the  digits.  The  skin  is  ill-nourished,  cold,  muddy  in  com- 
plexion, often  turgid  and  reddened.  It  is  often  glossy  about  the  nails 
and  the  fingers  are  tapered  with  overhanging,  claw-like  nails,  which  the 
patient  sometimes  refuses  to  trim  owing  to  the  tenderness  and  hyperes- 
thesia. Edema  is  not  infrequent  and  rarely  an  extra  deposit  of  fat  is 
encountered,  as  also  in  the  condition  named  adiposis  dolorosa  by  Der- 
cum,  but  ordinarily  the  fat  disappears  early.  Perspiration  is  reduced, 
or  more  rarely  increased,  causing  a  sodden  crumbling  of  the  epidermis. 
The  nails  and  hairs  may  become  coarse,  stiff',  and  fragile.  Herpetic 
eruptions,  erythema,  and  ulcerations,  so  frequent  in  an  ordinary  neuritis, 
are  very  uncommon. 

The  general  nutrition  is  usually  greatly  reduced  and  slight  elevations 
of  temperature  are  common.  In  the  infectious  forms  fever  may  naturally 
be  expected.  The  prolonged  toxic  or  cachectic  state,  which  usually 
antedates  the  onset  of  the  polyneuritis,  accounts  for  much  of  the  physi- 
cal depression,  but  some  of  it  is  apparently  due,  and  its  continuance  is 
partly  attributable,  to  the  lowered  functional  activity  that  pervades  the 
entire  nervous  system.  In  severe  and  prolonged  cases  difficulty  in 
swallowing,  an  inactive  stomach  and  intestine,  a  weakened  heart  and 
failing  circulation,  the  continuance  of  pain,  with  perhaps  insomnia  and 
mental  disturbance,  produce  a  marantic  depression  that  ends  fatally  or 
destroys  resistive  power  against  acute  infections  such  as  pneumonia. 
But  usually  the  general  state  can  be  maintained  at  a  satisfactory  level. 

Mental  Symptoms. — Following  Korsakoff,  a  number  of  writers  have 
sought  to  delimit  a  psychosis  peculiar  to  ]:)olyneuritis.  It  was  pointed 
out  by  Colella^  that  such  mental  disturbance  occurred  only  when 
the  patient  was  hereditarily  neuropathic.  Among  others,  Ferrari  ^  has 
shown  rather  conclusively  that  this   so-called  polyneuritic  psychosis  is 

1  "  Rivista  Sperimeutale, "  vol.  xx.  ^  "Alien,  and  Xeurol.,"  Jan.,  1896. 


314  DISEASES  OF  SPINAL  MENINGES  AND  SPINAL  NERVES. 

merely  the  mental  state  that  marks  chronic  poisoning  by  alcohol,  lead, 
and  other  toxic  substances,  and  has  something  in  common  with  the  con- 
fusional  insanity  that  sometimes  follows  infectious  fevers.  Charcot 
maintained  that  it  was  related  solely  to  alcohol,  but  Bury  ^  has  noted  it 
in  the  Manchester  epidemic  due  to  arsenic  in  very  moderate  beer  drinkers. 
Even  here,  however,  an  alcoholic  influence  can  not  be  denied.  However, 
the  association  of  mental  disturbance  with  polyneuritis  is  extremely  com- 
mon and  in  slight  degrees  is  easily  overlooked.  It  is  most  often  en- 
countered in  the  alcoholic  variety,  then  in  lead  cases  and  the  infectious 
multiple  neuritides.  In  some  cases  the  mental  condition  precedes  the 
appearance  of  neuritic  phenomena,  but  more  commonly  follows  the  onset 
of  the  polyneuritis  and  develops  progressively  with  it.  It  is  first  manifest 
in  a  change  of  temperament  and  character.  The  patient  becomes  irrita- 
ble, capricious,  and  exacting,  or  may  show  apathy  and  indolence.  This  is 
attended  or  followed  by  loss  of  sleep  and  the  nights  are  often  marked  by 
agitation  and  vague  alarm,  which  subside  with  the  day,  to  return  at 
evening.  Hallucinations  develop  as  the  malady  advances  and  may 
lead,  in  the  depressed  and  apprehensive  mental  state,  to  impulsive  acts 
of  a  self-protective  or  defensive  character.  The  patient  may  thus  attack 
or  abuse  those  about  him  or  seek  safety  in  flight.  These  marked  men- 
tal symptoms  may  still  subside  toward  morning,  but  finally  in  some 
cases  the  delirium  persists  night  and  day.  When  this  cerebral  condition 
occurs  it  usually  appears  comparatively  early  in  the  case,  and  corre- 
sponds, perhaps,  to  those  irritative  features  that  have  been  indicated  in 
the  peripheral  nervous  apparatus.  Convulsions  sometimes  most  clearly 
and  emphatically  demonstrate  the  cortical  irritation. 

As  the  paralytic  features  develop  in  the  limbs,  a  partially  demented 
condition  obtains  for  the  cerebrum.  Often  the  period  of  delirium  and 
excitement  is  not  evolved,  and  the  depressed  mental  condition  is  insidi- 
ously developed  primarily.  This  is  marked  most  prominently  by  a  for- 
getfidness  which  pertains  to  the  immediate  past  experiences  and  does  not 
notably  disturb  the  patient's  recollection  of  events  and  conditions  prior 
to  the  illness.  Such  a  patient  may  talk  rationally  and  logically  on  every 
possible  subject,  but  is  likely  to  forget  wdiat  he  has  said  or  heard  only  a 
few  moments  previously,  and  repeats  remarks  and  questions  at  short 
intervals  or  tells  the  same  story  over  and  over.  Because  of  this 
amnesia  he  is  frequently  at  fault  as  to  the  day  of  the  week  or  month, 
or  even  the  hour  of  the  day,  and  may  be  unable  to  tell  at  noon  what 
he  had  for  breakfast.  This  is  in  most  striking  contrast  with  the 
patient's  ability  to  remember  the  slightest  details  of  his  early  life,  with 
his  apparent  consciousness  of  his  surroundings,  and  with  his  ability  to 
logically  associate  facts  presented  to  him. 

In  addition  one  often  observes  what  at  first  would  seem  to  be  the 
play  of  a  diseased  imagination.  These  patients  may  assert,  perhaps  when 
already  confined  to  bed  for  months,  that  they  are  just  returned  from 
a  long  journey,  of  which  they  give  endless  and  minute  details,  name 
persons  encountered,  repeat  conversations  held  and  business  transacted, 
when  they  were,  in  fact,  unable  to  turn  over  in  bed.     Such  tales  are  re- 

^  Loc.  cit. 


MULTIPLE  NEURITIS.  315 

counted  in  the  most  ordinary  way,  without  the  slightest  excitement,  and 
completely  forgotten  in  a  short  time.  If  we  analyze  them  we  find  a 
mass  of  more  or  less  definite  incidents  or  purposes  transferred  from  the 
patient's  past  life  and  brought  down  to  the  date  at  wliich  they  are  re- 
counted, the  intervening  time  liaving  disappeared,  l^itients  will  speak 
of  having  just  seen  relatives  long  dead,  or  give  directions  for  the  enter- 
tainment of  persons  who  may  be  in  distant  parts  of  the  world.  If  their 
attention  is  called  to  these  discrepancies  they  first  try  to  maintain  their 
statements,  but  readily  become  mentally  confused  and  uncertain. 

This  amnesic  mental  condition  may  be  developed  in  all  grades  of 
intensity,  and  may  even  proceed  to  complete  dementia  and  a  fatal  termina- 
tion. The  bodily  strength  and  powers  of  assimilation  usually  are  cor- 
respondingly depraved.  The  mental  disorder  passes  away  as  the  case 
mends,  and  the  mind  is  usually  perfectly  clear  before  the  peripheral 
apparatus  is  fully  restored. 

Course  and  Special  Forms. — Polyneuritic  cases  present  many  clin- 
ical varieties  and  some  special  forms.  An  ordinary  case  may  be  outlined 
as  follows  :  The  first  complaint  is  of  tingling  or  formication  in  the  feet 
and  legs,  with  occasional  pains.  After  a  few  weeks  the  hands  and  fore- 
arms are  similarly  aifected  and  some  slight  loss  of  muscular  strength  is 
recognized.  The  sensory  and  motor  troubles  increase.  Pain  becomes 
more  prominent  and  the  paralytic  features  invade  the  thighs,  hips,  and 
perhaps  the  trunk  and  arms.  After  about  eight  weeks  the  malady  is 
full-fledged.  The  patient  now  walks  with  the  high  action,  the  muscles 
of  the  extremities  are  notably  wasted  and  give  the  electrical  reaction  of 
degeneration,  foot-drop  and  wrist-drop  are  well  marked,  and  the  reflexes 
are  diminished  or  abolished.  The  patient  is  uncertain  on  his  feet,  the 
legs  and  feet  readily  become  edematous,  red,  and  livid  ;  with  closed  eyes 
he  sways  and  perhaps  falls.  In  bed,  from  the  weakness  in  the  arms 
and  trunk,  he  can  not  gain  the  sitting  posture  without  help.  The  mus- 
cles and  nerve-trunks  are  sensitive  to  pressure  ;  there  is  some  anesthesia 
or  at  least  much  blunting  and  retardation  of  the  cutaneous  sensations, 
and  much  sensitiveness  in  certain  cases.  The  skin  is  dry  and  thinned 
about  the  digits  and  base  of  the  nails.  At  this  time  mental  disturb- 
ance is  likely  to  appear.  After  this  state  is  reached  the  case  remains 
almost  stationary  for  several  months ;  then  the  sensory  disturbances 
diminish  slowly,  the  pains  decrease,  the  anesthesia  disappears ;  the 
muscles  regain  their  former  proportions,  strength,  and  reactions  ;  the 
reflexes  reappear,  and  full  recovery  is  established,  after  about  twelve 
months  from  the  onset  of  the  disease.  Very  often  anesthetic  areas  be- 
come hyperesthetic  and  the  pains  increase  as  regeneration  passes  down- 
ward. In  some  instances  the  disease,  instead  of  coming  to  a  standstill, 
progresses  to  a  fatality  by  involving  the  muscles  of  the  trunk,  of  respira- 
tion, deglutition,  and  circulation.  Death  results  from  pneumogastric 
involvement.  In  other  cases  the  development  of  fibrotendinous  con- 
tractures disables  the  patient  after  convalescence  until  surgically  relieved. 
Again,  the  progress  of  the  disease  may  be  much  varied.  It  may  com- 
mence insidiously  and  then  advance  with  great  rapidity,  or,  commencing 
suddenly,  quickly  reach  its  maximum  and  then  slowly  or  quickly  sub- 


316  DISEASES  OF  SPINAL  3IENINGES  AND  SPINAL  NERVES. 

side.  When  atrophy  is  well  marked,  restoration  is  always  a  tedious 
affair.  As  a  rule,  in  the  cases  that  recover  full  health  is  regained, 
but  in  a  few  cases  localized  atrophies  and  contractures  remain  perma- 
nently. 

Other  clinical  varieties  depend  on  the  location  of  the  prominent 
symptoms  of  the  disease.  The  cranial  nerves,  the  upper  extremities,  or 
the  lower  limbs  may  be  most  affected.  Some  cases  show  a  prepon- 
derance of  motor  disability,  others  of  sensory  disturbance.  The  rare 
cases  marked  at  first  by  increased  reflexes,  increased  electrical  responses, 
marked  hyperesthesia,  and  perhaps  a  tendency  to  delirium,  must  not  be 
overlooked. 

In  addition  there  is  a  small  group  of  very  acute  cases  in  which  the 
disease,  beginning  in  the  feet  and  legs,  rapidly  invades  the  thighs,  the 
trunk,  the  upper  extremities  (commencing  in  the  fingers  and  gradually 
passing  up  the  limbs  to  the  shoulder),  and,  finally  involving  the  dia- 
phragm and  the  bulbar  nerves,  reaches  a  fatal  termination  in  from  six 
to  twenty  days.  By  some  writers  this  form  is  considered  identical  with 
Landry's  paralysis,  but  by  others  is  distinguished  from  it  by  the  disturb- 
ance of  sensation  and  reflexes  and  the  postmortem  presence  of  changes 
in  the  nerve-trunks.  Any  sharp  distinction  is  arbitrary  and  untenable, 
as  all  gradations  between  multiple  neuritis  and  acute  ascending  myelitis 
are  encountered.  ^ 

Certain  toxic  elements  cause  a  polyneuritis  marked  by  peculiar  and 
even  characteristic  symptom  groups  that  merit  brief  attention. 

The  alcoholic  form,  besides  being  the  most  usual  polyneuritis, 
presents  with  considerable  uniformity  the  following  features :  The 
lower  extremities  are  the  most  affected,  and  the  painful  sensory  dis- 
turbances reach  their  highest  range  in  this  toxic  state.  They  are  pro- 
portionately much  more  pronounced  than  the  paralytic  conditions.  The 
paresthesise  are  particularly  intense  and  intolerable.  The  muscles  and 
nerves  are  especially  sensitive,  and  cutaneous  hyperesthesia  is  exquisitely 
developed.  The  high-action  gait  is  usually  well  marked,  as  the  exteur- 
sors  of  the  leg  are  generally  affected  with  the  muscles  below  the  knee. 
Atrophy  is  well  marked  and  the  tendency  to  fibrotendinous  contracture 
is  very  strong.  Involvement  of  the  ocular  muscles  is  comparatively 
frequent  and  bilateral  scotomatous  amaurosis  is  common.  Of  all  forms, 
alcoholic  polyneuritis  furnishes  by  far  the  greatest  number  of  cases  of 
mental  disturbance.  Recovery  is  comparatively  rapid  if  alcohol  can  be 
withdrawn,  Relapses  are  probable,  and  a  single  indulgence  before  the 
disease  is  definitely  at  an  end  may  cause  the  most  startling  reappearance 
and  exaggeration  of  all  the  former  symptoms. 

Lead-palsy  in  typical  cases  presents  some  or  all  of  the  following 
conditions  :  It  usually  comes  on  after  prolonged  exposure  to  intoxication 
through  the  patient's  occupation,  or  by  the  use  of  drugs  and  cosmetics, 
or  by  drinking  contaminated  water.  The  source  of  the  lead-poisoning 
is  often  extremely  puzzling  and  requires  the  most  painstaking  search. 
The  paralytic  features  are  usually  preceded  by  colics  and  constipation, 
and  may  develop  at  a  long  period  of  months  after  the  patient  has  been  re- 
1  Mediu,  "  Arch,  de  Med.  des  Enfants,"  1898. 


MULTIPLE  NEURITIS.  '  317 

moved  from  the  source  of  intoxicatiou.  In  other  cases  the  administration 
of  alkaline  iodids  to  one  impregnated  with  lead,  but  showing  no  marked 
symptoms  of  it,  may  precipitate  the  neuritis.  The  upper  extremities 
are  first  and  almost  exclusively  affected.  The  distribution  of  the  palsy 
is  practically  symmetrical,  but  the  right  hand  is  most  disabled  in  right- 
handed  patients,  the  opposite  hand  in  the  left-handed.  Sensory  dis- 
turbance in  the  hands  is  practically  absent,  but  if  the  legs  are  affected 
cutaneous  sensibility  is  changed  and  pains  are  usually  present  below  the 
knees.  The  muscular  wasting  is  prominent,  and  in  some  cases  seems  to 
be  the  primal  disorder,  bringing  these  cases  into  apparent  relation  with 
the  myopathies.  Most  cases  show  the  wrist-drop  feature,  but  arm  and 
shoulder  types  may  be  encountered  alone  or  may  be  gradually  added  to 
the  first  form,  establishing  an  appearance  of  relationship  with  the  spinal 
myopathies.  The  muscles  of  the  larynx  are  frequently  affected,  as 
shown  by  aphonia.  The  retrocarpal  tumor  is  usually  developed.  Ocular 
disturbances  are  frequent,  and  due  to  optic  neuritis,  fi'om  which  sudden 
blindness  may  occur.  When  the  trunk  and  bulbar  muscles  are  involved, 
the  outlook  is  better  than  in  the  alcoholic  variety  under  similar  circum- 
stances. The  course  is  usually  insidious  at  the  beginning  and  protracted 
throughout. 

Lead-palsy  also  has  its  associated  mental  disturbance.  In  rare  cases 
this  resembles  the  one  so  usual  in  alcoholic  polyneuritis  sketched  at  page 
314,  with  marked  visual  hallucinations  and  amnesia.  Lead,  however, 
has  its  own  cerebral  disorders.  These  are  an  acute  mania  and  a  condi- 
tion that  presents  all  the  somatic  indications  of  general  paresis,  but  is 
usually  marked  by  mental  sluggishness  and  is  devoid  of  the  expansiveness 
of  true  paretic  dementia.  In  addition  lead  may  engender  general 
cerebral  affections  by  its  action  on  the  circulation,  mainly  by  the  arterio- 
sclerosis and  kidney  disorders  it  induces.  Delirium,  convulsions,  coma, 
hemiplegia,  and  combinations  of  these  are  frequently  encountered  in 
plumbism. 

Diphtheric  Paralysis. — The  term  paralysis  is  selected  purposely, 
as  a  neuritis  can  not  always  be  demonstrated  in  these  cases.  Hochhaus 
found  only  the  muscles  affected,  and  Babinski,  in  rabbits  paralyzed  by 
injections  of  the  toxins  derived  from  the  Klebs-Loffler  bacillus,  found 
no  changes  whatever.  In  certain  cases,  however,  a  periaxial  neuritis 
is  clearly  demonstrable.  What  the  conditions  are  that  determine  a 
neuritis  in  one  case  and  leave  no  trace  in  others  can  not  now  be  stated. 
The  result  in  both  instances  is  undoubtedly  due  to  the  action  of  the 
toxins  evolved  in  the  life-history  of  the  bacillus  of  diphtheria.  Diph- 
theric palsy  may  appear  after  all  forms  of  the  initial  malady,  what- 
ever its  apparent  intensity  or  bodily  location.  Ware,  for  instance, 
reports  a  typical  case  with  the  usual  pharyngeal  palsy,  the  diphtheric 
membrane  being  located  on  the  vulva.  It  seems  to  be  rather  more 
common  in  adult  cases,  perhaps  because  the  palatal,  pharyngeal,  and 
pneumogastric  involvement  in  infants  may  lead  to  a  fatal  termina- 
tion without  being  attributed  to  a  nerve-lesion.  Ordinarily,  it  appears 
during  convalescence  in  from  one  to  three  weeks  after  the  diphtheria 
has  subsided,  but  may  develop  within  a  day  or  two  of  the  appearance  of 


318  DISEASES  OF  SPINAL  MENINGES  AND  SPINAL  NERVES. 

the  pseudomembrane.  The  muscles  of  the  soft  palate  and  the  pharynx 
are  the  first  to  suffer,  as  a  rule,  and  the  paralysis  may  extend  to  the  lips, 
cheeks,  and  tongue.  If  it  spreads  further,  the  legs  next  suffer.  The 
knee-jerks  are  often  abolished,  even  before  the  palate  is  disturbed.  The 
upper  extremities  and  the  trunk  are  invaded  only  in  exceptional  cases. 
The  muscles  of  the  neck,  on  the  contrary,  are  frequently  weakened,  so 
that  the  head  may  roll  about  helplessly  on  the  shoulders.  The  affected 
muscles  rarely  waste  and  contractures  hardly  ever  develop.  Sensory 
changes  consist  of  insensibility  in  the  affected  parts,  as  in  the  pharynx, 
larvnx,  etc.  Much  pain  and  painful  paresthesia  are  wanting.  There 
is  usually  some  ataxia  in  the  extremities  and  Romberg's  sign  is  seen. 
At  the  time  the  palatal  difficulties  appear  there  is  usually  some  loss  of 
visual  acuity,  especially  for  near  objects,  which  is  due  to  the  character- 
istic paralysis  of  accommodation,  but  the  pupils  do  not  fail  to  act. 
Strabismus,  double  vision,  and  ptosis  are  not  uncommon.  In  adults, 
sexual  impotence  is  frequently  developed.  Mental  symptoms  almost 
never  occur.  Diphtheric  palsy  is  of  rapid  development  and  usually 
terminates  in  recovery.  If  only  the  palate  is  affected,  cure  is  reached 
in  two  or  three  weeks ;  in  more  generalized  forms  the  disability  is  pro- 
longed to  three  or  four  months,  or  even  to  a  year  in  severe  cases.  If 
death  occurs,  it  may  be  attributable  to  the  cachexia  and  inanition  from 
inability  to  swallow  or  may  be  caused  by  pneumogastric  paralysis.  In- 
spiration pneumonia  is  also  likely  to  carry  off  the  patient.  In  very  rare 
cases  of  diphtheric  palsy  the  paretic  features  are  fleeting,  and  change 
from  place  to  place  or  disappear  and  return.  These  cases  are  more 
frequent  since  the  general  use  of  antitoxin  in  the  treatment  of  diph- 
theria, probably  because  cases  are  now  saved  that  otherwise  would  have 
terminated  fatally. 

Erythromelalg-ia  is  a  variety  of  multiple  neuritis  affecting  princi- 
pally the  plantar  nerves,  and  first  described  by  Weir  Mitchell  as  a  vaso- 
motor neurosis.  Collier  ^  reports  ten  cases  of  erythromelalgia  in  organic 
nervous  disorders  :  six  of  insular  sclerosis,  three  of  tabes,  and  one  of  mye- 
litis. It  may  also  occur  with  decided  arterial  changes,  but  undoubtedly 
is  a  neuritis,  as  proven  by  Mitchell  and  Spiller.^  It  usually  attacks  men, 
and  is  worse  at  night  and  after  walking.  The  feet  become  intensely  red 
and  show  some  swelling.  The  pain  is  of  a  burning  sort  and  the  attend- 
ing perspiration  may  be  profuse.  Heat  aggravates  and  cold  relieves  the 
distress.  An  elevated  position  also  affords  relief.  Walking  may  become 
so  painful  as  to  be  impossible.  Trophic  disturbance  in  the  skin  in  severe 
cases  is  encountered.  The  condition  may  get  well  spontaneously  or  be 
very  persistent.  Rest  in  bed,  electricity,  massage,  and,  in  protracted 
cases,  excision  of  the  posterior  tibial  nerve  have  been  advised. 

Beri-beri,  or  kakke,  is  a  polyneuritis  that  apparently  depends 
upon  a  specific  infection.  Several  investigators  have  found  various 
micro-organisms  which  they  have  thought  to  be  the  pathogenic  agents, 
but  there  is  as  yet  a  lack  of  uniformity  and  confirmation.  There  are 
those  who  insist  that  it  is  due  to  carbonic  gas  poisoning.  Others  have 
attributed  it  to  a  diet  of  fish  or  rice.    It  arises  when  people  are  huddled 

1  "Lancet,"  Aug.  13,  1898.  ^  a^^^^   j^^^^,   j^j^^   g^j    ,,  j^^^     jggg^ 


MULTIPLE  NEURITIS.  319 

together  in  prisons,  asylums,  barracks,  or  on  shipboard,  and  is  particu- 
larly common  in  China,  Japan,  and  India,  and  in  South  and  Central 
America.  It  is  marked  by  paralytic  and  atrophic  disorders,  especially 
in  the  lower  limbs,  and  particularly  in  the  antero-external  leg  muscles, 
producing  the  characteristic  gait.  The  phrenic  and  pneumogastric 
nerves  suiFer  early,  and  respiratory  and  cardiac  symptoms  are  promi- 
nent. The  face  and  tongue  are  frequently  aifected.  The  sensory  dis- 
orders are  mainly  anesthesia  and  severe  lightning-like  pains.  Edema 
of  the  lower  extremities  is  often  very  great.  It  may  also  invade  the 
trunk  and  flood  its  cavities.  The  knee-jerks  are  lost  early.  There  is 
frequently  right  cardiac  dilatation,  rapid  heart  action,  and  murmurs 
over  the  base.  Mental  disturbance,  similar  to  that  in  alcoholic  cases, 
is  frequently  observed.  All  degrees  of  severity,  from  simple  weakening 
of  the  lower  extremities,  with  cardiac  palpitation,  to  a  pernicious  acute 
form,  like  an  acute  ascending  myelitis  that  runs  to  a  fatal  termination 
in  a  few  days  are  presented.  Intermediate  varieties  may  be  marked 
most  by  atrophy  or  by  edema,  and  are  very  long  in  recovering,  with 
death  always  likely  from  pneumogastric  accidents.  A  large  proportion 
of  cases  are  said  to  have  intestinal  parasites.  H.  Wright  ^  found 
changes  in  the  cells  of  the  posterior  root  ganglia  and  the  anterior  horns 
of  the  cord  in  eight  consecutive  cases. 

Leprous  Neuritis. — The  invasion  of  the  nerves  by  the  leprous 
bacillus  sets  up  a  multiple  neuritis.  There  is  a  marked  tendency  to 
fibroid  proliferation  in  the  nerve-trunks,  which  often  become  nodular, 
and  eventually  the  bacilli  disappear.  The  spinal  cord  is  exceptionally 
invaded  by  the  bacillus  (Souza,  Martins),  and  presents  central  cavities, 
especially  in  the  posterior  horns  and  gray  commissure.  The  prominent 
sensory  disturbance  is  anesthesia,  which  occurs  in  discrete  plaques,  favor- 
ing in  location  the  hands,  feet,  forearms,  legs,  and  face.  By  spreading, 
an  entire  member  or  a  large  portion  of  the  body  may  become  anesthetic, 
and  the  deep  parts,  muscles,  bones,  etc.,  are  also  involved.  Muscular 
atrophies  are  comparatively  slight,  and  most  aifect  the  small  muscles  of 
the  hands,  feet,  and  face.  Atrophic  conditions  in  the  hands  and  feet 
lead  to  mutilations  of  the  extremities.  Fingers,  toes,  and  even  hands 
and  feet  necrose  and  are  cast  off.  The  evolution  of  the  neuritis  is 
extremely  slow,  and  may  extend  over  a  score  of  years. 

In  some  cases  a  dissociation  of  cutaneous  sensation  is  encountered 
similar  to  that  of  syringomyelia,  especially  of  the  Morvan  type,  and 
probably  due  to  the  cord  lesions  previously  noted. 

Recurrent  multiple  neuritis  as  a  variety  has  been  described  by 
Sherwood,  Ross,  Dreschfeld,  Targlowa,  Klumpke,  and  Osier.  Thomas^ 
also  reports  a  case.  It  appears  that  certain  individuals  are  susceptible 
to  repeated  attacks  from  various  poisons,  but  particularly  from  lead 
and  alcohol.  It  is  not  requisite  that  the  patient  be  exposed  to  the 
intoxicant  to  induce  a  recurrence  of  the  neuritis,  and  it  is  unde- 
termined whether  there  is  an  original  susceptibility  or  the  first  attack 
leaves  a  predisposition  to  its  return. 

1  "  Br.  Med.  Jour.,"  June  29,  1901.       ^  "  PhUa.  Med.  Jour.,"  May  14,  1898. 


320 


DISEASES  OF  SPINAL  MENINGES  AND  SPINAL  NERVES. 


Diagnosis. — The  diagnosis  of  a  case  of  well-marked  multiple  neu- 
ritis, based  upon  a  fairly  full  history  and  a  detailed  examination,  can 
hardly  be  missed  ;  but  in  the  early  stages,  when  a  diagnosis  is  of  most 
importance,  it  is  frequently  extremely  difficult.  The  major  items  upon 
wdiich  it  then  rests  are  the  motor  and  sensory  symptoms,  their  sym- 
metrical distribution,  their  predominance  in  the  ends  of  the  extremities, 
the  more  marked  aifection  of  the  extensors,  the  modification  of  the 
reflexes,  the  tenderness  of  nerve-trunks  and  muscles,  and  the  history 
or  presence  of  some  toxic  agent  capable  of  producing  the  neuritis.  A 
multiple  neuritis  may  be  confounded  with  several  diseases  of  the  spinal 
cord,  especially  poliomyelitis  anterior  and  locomotor  ataxia.  The  fol- 
lowing differential  tables  may  help  to  distinguish  them  : 


Poliomyelitis. 

Most  frequent  in  children. 
Onset  abrupt. 
Embraces  entire  limbs. 
Not  usually  symmetrical. 
Immediate  tendency  to  improvement. 
Sensory  symptoms  slight  or  absent. 
No  mental  symptoms. 
Usually  leaves  some  deformity. 


Multiple  Neuritis. 

In  adults. 

Insidious. 

Begins  in  ends  of  limbs. 

Symmetrical. 

Gradual  extension. 

Sensory  disturbance  early  and  persistent. 

Mental  symptoms  common. 

Recovers  completely. 


Locomotor  Ataxia. 
Girdle  pains  and  lightning  pains  early. 

Nerve-trunks  often  insensitive. 

Muscular  sense  disturbed  early. 

Amyotrophia  and  reaction  of  degenera- 
tion absent. 

Peculiarity  of  gait  due  to  incoordina- 
tion and  irrespective  of  muscular 
strength . 

Strikes  heels  first  and  does  not  follow 
straight  line. 

Circulation  and  trophic  condition  of 
limbs  normal. 

Perforating  ulcers,  joint  lesions,  and  oste- 
opathies are  common. 

Argyll-Robertson  phenomenon  usual. 

Optic  atrophy  common. 

Vesical  troubles  frequent  and  early. 

Gastric  and  intestinal  crises. 

Fecal  incontinence  common. 

Sometimes  followed  by  paretic  dementia. 

Of  slow  evolution,  requiring  years. 

Incurable. 

Syphilis  usually  in  the  history. 


Multiple  Neuritis. 

No  girdle  pains ;  lightning  pains  infre- 
quent. 

Usually  oversensitive  and  often  thick- 
ened. 

Only  slightly  disturbed  or  intact. 

Develop  early. 

Due  to  paresis  and  proportionate  to 
loss  of  power. 

Strikes  toes  and    outer  border  of  foot 

first  and  walks  in  straight  line. 
Edema,  lividity,  and  epithelial  changes. 

Rare  or  unknown. 

Never  present. 

Rare,  but  toxic  amaurosis  frequent. 

Very  exceptional  and  late. 

Dyspepsias  from  toxic  causes,  consti- 
pation from  lead,  etc. 

Only  in  acute  pernicious  cases  and  in 
stuporous  states. 

Often  accompanied  by  mental  disturb- 
ance. 

Of  insidious,  progressive  develop- 
ment, requiring  months. 

Recovers  if  patient  survives. 

Antecedent  intoxications,  infections,  and 
cachexias. 


3IyeUtis  is  distinguished  from  polyneuritis  by  the  girdle  pains,  the 
paraplegia,  the  anesthesias,  the  retention  of  electrical  responses  in  many 
of  the  paralyzed  muscles,  and  the  presence  of  the  deep  reflexes,  which 


MULTIPLE  NEURITIS.  321 

usually  are  extremely  exaggerated.  In  this  disease  bedsores  are  com- 
mon ;  in  polyneuritis  well-nigh  unknown.  The  sphincters  are  usually 
beyond  ordinary  control  in  myelitis  and  practically  unaffected  in  neuritis. 

Hysteria  is  sometimes  confounded  with  polyneuritis,  and,  indeed,  both 
may  be  present  in  the  same  patient,  but  should  none  the  less  be  separately 
recognized.  The  pain  in  hysteria  lacks  sincerity  of  facial  expres- 
sion and  the  deep  muscular  masses  are  practically  never  sensitive. 
Hysterical  anesthesia  is  segmental,  and  rarely  involves  all  four  extrem- 
ities symmetrically.  The  reflexes  and  electrical  reactions  are  present  in 
hysteria — there  is  no  wasting,  no  cutaneous  dystrophy.  The  evolution 
of  hysterical  trouble,  its  emotional  concomitants,  and  its  stigmata  are 
sufficiently  significant. 

The  pernicious  anemias  often  present  reduced  reflexes,  paresthesias  in 
the  extremities,  uncertain  gait,  mental  vagueness,  and  general  muscular 
weakness.  A  careful  blood  examination  shows  characteristic  cellular 
changes  (see  page  448). 

The  diagnosis  of  the  toxic  cause  and  its  origin  is  usually  made  in 
securing  the  history  or  in  making  the  examination  of  the  patient,  but 
many  times  presents  great  and  even  insuperable  difficulties.  The  alco- 
holic, lead,  and  diphtheric  types  of  polyneuritis  are  themselves  signi- 
ficant of  their  origin.  Alcoholic  addiction  is  frequently  denied,  espe- 
cially by  women.  Patients  may  even  be  unaware  that  they  are  taking 
large  quantities  of  alcohol  in  the  form  of  various  nostrums  and  patent 
medicines.  The  absence  of  the  lead  line  on  the  gums  should  not  mis- 
lead, as  it  only  occurs  where  there  is  some  local  disturbance  about  the 
necks  of  the  teeth.  A  dose  of  iodid,  followed  by  an  analysis  of  the 
urine,  may  show  plenty  of  lead.  Hair-dyes,  face-powders,  and  styptic 
applications  or  injections  may  contain  lead,  and  the  polyneuritis  may 
appear  several  months  after  their  discontinuance.  Arsenic  and  lead  in 
fabrics,  paints,  wall-paper,  toys,  and  medicinal  prescriptions  are  to  be 
borne  in  mind.  In  diphtheria,  if  the  patient  has  been  exposed,  it  is  not 
necessary  to  have  a  pseudomembrane  or  even  a  history  of  a  sore  throat 
in  order  to  attribute  the  palsy  to  the  proper  source.  Leprosy  and  beri- 
beri are  distinguished  by  their  infectious  and  clinical  peculiarities. 
There  remains  the  great  class  of  infections  arising  from  intestinal  fer- 
mentation and  the  infectious  diseases,  which  must  be  deciphered  from 
the  history  and  examination  of  the  patient. 

Prognosis. — It  may  be  laid  down  as  a  general  rule  that  if  the  cause 
of  a  polyneuritis  can  be  removed,  the  patient  has  a  very  good  chance  of 
complete  recovery,  and  that  recovery  is  the  most  common  termination 
of  the  disease.  The  prognosis  is  to  be  modified  in  accordance  with  the 
nature  of  the  pathogenic  agent,  the  mode  of  evolution  of  the  disease, 
its  intensity,  extent,  and  localization,  and  the  general  physical  condition 
of  the  patient.  Diphtherial  polyneuritis,  unless  the  patient  succumbs 
in  the  early  days  of  the  attack,  is  the  most  benign  form,  and  rapidly 
terminates  in  recovery.  Lead  palsy  alone  very  rarely  causes  death,  but 
is  usually  attended  by  a  bad  general  state  and  is  of  long  duration  and  a 
disabling  character.  Alcoholic  neuritis  is  more  frequently  fatal  and  is 
customarily  associated  with  other  organic  disease  due  to  the  same  cause. 
21 


322 


DISEASES  OF  SPINAL  JIENIXGES  AND  SPINAL  NEEVES. 


The  intense  painful  conditions  that  attend  it  and  the  debilitating-  suffer- 
ing, with  the  tendency  to  mental  disturbance,  give  to  the  alcoholic  form 
a  high  grade  of  gravity.  Auto-intoxication  arising  from  the  intestine  usu- 
ally is  the  result  of  chronic  and  intractable  bowel  disease,  and  is  corre- 
spondingly protracted  and  unmanageable.  Acute  invasion  and  rapid 
evolution  of  a  polyneuritis  lead  at  once  to  the  apprehension  of  respira- 
tory and  cardiac  failure  and  an  early  fatal  termination.  On  the  other 
hand,  an  insidious  onset  and  slow  advancement  imply  chronic  tenacity 
and  a  prolonged  impairment  of  powers,  with  slow  convalescence. 

The  gravity  of  a  polyneuritis  is  in  some  proportion  to  its  extent,  par- 
ticularly in  relation  to  its  advancement  toward  the  trunk,  implying  great 
helplessness,  and   toward  the  pneumogastric,  implying  fatal  accidents 
from  its  implication.    The  presence  of  cerebral  symptoms,  such  as  psycho- 
ses or   convulsions,  and  of 
spinal  involvement,  as  shown 
by. loss  of  sphincter  control, 
add  greatly  to  the  gravity 
of  the  outlook.    The  general 
state,  the  powers  of  diges- 
tion,  assimilation,    and  the 
ability  to  sleep  have  a  strong 
bearing  on  the  recuperative 
prospects  of  the  patient. 

Treatment. — The  first 
element  in  the  treatment  of 
a  multiple  neuritis  naturally 
is  the  removal  of  the  cause. 
In  alcoholic  cases  this  is  fre- 
quently a  matter  of  great 
difficulty  unless  the  patient 
can  be  placed  under  the  care 
of  a  trained  nurse  or  in  a 
hospital.  In  some  instances 
the  immediate  withdrawal 
of  alcohol  is  attended  with 
a  great  deal  of  physical  and  mental  disturbance,  but  half-way  measures 
usually  only  prolong  the  agony  and  frequently  fail  completely.  After 
such  a  case  has  made  decided  improvement  and  if  taken  early  this  may 
promptly  appear  ;  a  very  little  indulgence  in  alcohol  is  likely  to  cause 
the  return  of  all  former  symptoms.  Very  moderate  drinking  is  capable 
of  maintaining  them  indefinitely. 

Lead  can  be  eliminated  from  the  system  by  the  use  of  the  alkaline 
iodids  and  sulphates,  but  some  care  must  be  taken  not  to  Ulcerate  the 
metal  too  rapidly,  as  cerebral  disturbance  and  an  increase  of  the  paralytic 
features  may  be  precipitated.  They  should  be  commenced  in  small  but 
increasing  doses,  and  aided  by  elimination  from  the  skin,  kidneys,  and 
especially  from  the  constipated  bowels.  Occupations  giving  rise  to  such 
poisoning  must  be  given  up  entirely,  as  even  when  crmvalescence  has 
been  long  established  a  relapse  is  likely  to  quickly  f(.lIo^v  a  return  to 
the  former  work. 


Fig.  117.— The  upper  figure  represents  the  shape  of  the 
brown-paper  pattern,  and  of  the  leather  cut  in  correspond- 
ence to  it.  The  dimensions  are  approximate,  Tarving  -with 
each  leg;  d  is  the  narrowing  for  the  knee,  that  the  leather 
may  not  press  on  tlie  bone  at  the  sides;  6  is  the  excaTation 
on  each  side  for  the  ankle  with  the  narrow  connecting  piece 
of  leather,  which  is  the  special  feature  of  the  contrivance. 
This,  1  to  \y^  inches  wide,  and  no  longer  than  is  needful, 
affords  lengthwise,  adequate  support  to  make  the  pull  from 
above  act  down  on  the  foot-piece  on  which  the  pull  acts  ;  at 
h  and  g  are  the  rings  for  the  cords;  the  cords  are  here 
shown  only  as  going  to  the  lower  rings ;  if  there  is  contrac- 
tion of  the  knee,  they  should  be  carried  through  these  rings 
and  fastened  to  the  "other  rings  above  the  knee:  if  there  is 
no  contraction  of  the  knee,  it  is  not  necessary  for  the  leather 
to  extend  above  the  knee  (after  Gowers). 


MULTIPLE  NEURITIS.  323 

In  auto-intoxications  from  intestinal  fermentation  a  restricted  diet  and 
the  use  of  those  antiseptics  which  tend  to  inhibit  bacterial  activity  and 
reduce  toxicity  are  indicated.  In  diphtheria  the  source  of  infection 
subsides  with  the  cessation  of  the  bacillary  invasion.  In  the  poison- 
ings following  acute  infections  the  toxemic  state  requires  attention  and 
is  best  controlled  by  very  large  doses  of  iron,  especially  the  tincture  of 
the  chlorid,  Ijy  salol,  and  similar  drugs.  If  a  malarial  element  is  pres- 
ent, quinin  and  arsenic  are  required.  The  various  cachexias  that  are 
attended  by  the  development  of  multiple  neuritis  unfortunately  are  rarely 
amenable  to  treatment.  In  tuberculosis  and  cancer,  the  measures  which 
produce  improvement  in  the  general  state  benefit  the  neuritis. 

The  general  physical  condition  in  all  cases  requires  attention  from 
first  to  last,  and  one  of  the  chief  items  in  this  connection  is  rest  for  the 
weakened  muscles.  This  frequently  means  rest  in  bed.  In  all  marked 
cases  such  rest  is  obligatory.  In  the  acute  cases  that  rapidly  involve 
respiration  and  threaten  the  pneumogastric  the  greatest  care  must  be 
taken  to  prevent  pneumonic  inflammation.  At  the  same  time  the  alimen- 
tation and  support  of  the  patient's  strength  frequently  require  the  use 
of  the  esophageal  tube  by  the  way  of  the  nose  or  mouth,  or  rectal  feed- 
ing may  be  employed.  From  first  to  last,  also,  measures  must  be  taken^ 
especially  in  alcoholic  cases,  to  prevent  contractures  and  posture  deformi- 
ties. These  usually  are  confined  to  the  lower  extremities.  Foot-drop 
and  inversion  of  the  sole  constitute  the  ordinary  deformity,  but  the  knees 
and  hips  are  also  frequently  involved  in  a  semiflexion  made  rigid  by 
tendinous  contractures  and  rarely  by  joint-adhesions.  The  weight  of 
bed-clothing  serves  to  increase  the  foot-drop,  and  must  be  taken  off  the 
toes.  So  far  as  possible  the  feet  should  be  kept  at  a  right  angle  with 
the  legs  and  the  knees  and  hips  extended.  The  sensitiveness  of  the 
skin  and  the  pains  in  the  limbs  often  defeat  attempts  to  use  any  fixation 
apparatus  such  as  light  splints,  but  if  commenced  early,  they  can  often 
be  worn  with  great  advantage.  Pillows  may  be  so  placed  as  to  support 
the  feet  and  remove  the  weight  of  bed-covering.  Passive  movements 
in  full  extension  and  especially  full  dorsal  flexion  of  the  feet  on  the  legs 
should  be  gently  used  several  times  daily. 

In  early  stages  the  use  of  hot  or  cold  applications  has  been  recom- 
mended, but  probably  does  little  good,  aside  from  slightly  relieving 
the  pain.  Vesication  and  strong  stimulation  by  counterirritation  must 
be  avoided,  owing  to  the  likelihood  of  producing  indolent  ulceration. 
Vigorous  massage  and  electrization  that  produces  firm  contraction  of 
the  muscles  are  also  contraindicated  at  first.  Gentle  strokings  or 
kneadings  of  the  muscles  that  do  not  cause  pain  or  distress  are  often 
very  grateful  to  the  patient,  aid  return  circulation,  and  favor  local  nutri- 
tion. Hot  baths,  needle  douches,  Turkish  and  Russian  baths,  and  vig- 
orous measures  generally  should  be  reserved  until  the  disease  has  passed 
its  maximum. 

The  question  of  anodynes  here,  as  in  sciatica  and  other  prolonged 
painful  affections,  is  one  requiring  mature  judgment  and  great  conserv- 
atism. The  coal-tar  derivatives  sometimes  act  well  and  are  not  so 
objectionable  as  opiates  and   cocain,  which  alone  seem  capable  of  con- 


324  DISEASES  OF  SPINAL  MENINGES  AND  SPINAL  NERVES. 

trolling  the  pains  in  the  severest  cases.  Chloral  and  bromids  combined 
are  the  surest  sleep-producers. 

After  the  disease  has  reached  its  stationary  period  more  vigorous 
local  measures  should  be  instituted.  Massage  of  the  weakened  muscles 
and  their  exercise  by  galvanic  electricity  should  be  faithfully  and  sys- 
tematically carried  out  once  or  twice  daily.  The  wasted  muscles 
frequently  respond  to  static  sparks  before  they  will  to  the  constant  cur- 
rent, and  this  form  of  electricity,  if  available,  will  then  render  good 
service.  A  faradic  brush  or  static  sparks  also  seem  to  beneficially 
influence  cutaneous  anesthesia  and  hyperesthesia.  The  patient  must 
be  urged  to  use  the  limbs,  and  at  the  first  possible  moment  to  bear 
weight  on  the  feet  and  get  the  heels  to  the  floor. 

In  cases  of  long  standing,  when  the  contractures  are  strongly  devel- 
oped, stretching,  under  anesthesia,  and  the  application  of  fixative  dress- 
ings may  be  done,  and,  if  this  does  not  suffice,  tenotomies  are  in  order. 
In  chronic  cases  of  wrist-drop  the  use  of  splints,  as  described  on  page 
290,  will  often  be  found  of  signal  service.  Here,  too,  courses  of  hot 
baths,  especially  if  combined  with  intelligent  massage,  hot  douches,  the 
Scotch  douche,  and  Turkish  baths,  are  serviceable  if  the  general  condi- 
tion of  the  patient  does  not  contraindicate  their  use. 


CHAPTER  V. 

HERPES  ZOSTER. 

Herpes  zoster,  also  known  as  zoster,  zona,  and  more  commonly  as 
shingles  (Lat.  cingulum),  is  an  acute  infectious  disorder  beginning  with 
pain,  soreness  and  burning  in  a  given  segmental  skin  area,  followed  by 
discrete  groups  of  papules  on  a  reddened  and  swollen  base,  after  a  few 
days  showing  turbid  and  purulent  contents,  and  later  brown  crusts  which 
fall  by  the  end  of  the  second  week,  leaving  reddened  or  pigmental 
patches  and  occasionally  scars.  There  is  sometimes  fever  in  the  initial 
stage  which  with  the  pain  subsides  upon  the  appearance  of  the  eruption. 
Secondary  infection  of  the  eruption  may  complicate  the  course  and 
termination  of  the  disease.  The  lesion  is  an  acute  hemorrhagic  inflam- 
mation of  the  corresponding  posterior  root  ganglia.  The  favorite  loca- 
tion is  on  the  head  or  face  and  about  the  trunk,  but  any  portion  of  the 
cutaneous  expanse  may  be  affected. 

Etiology. — The  exact  nature  of  the  infection  in  herpes  zoster  is 
not  yet  determined,  but  it  presents  seasonal,  epidemic,  contagious  and 
self-limited  peculiarities.  To  this  infection,  or  the  toxin  therefrom 
arising,  the  posterior  root  ganglia  show  a  decided  susceptibility,  but 
commonly  one  only  is  affected  in  a  given  case.  Certain  ganglia,  more- 
over, are  more  prone  to  attack  than  others,  namely,  the  Gasserian  and 
those  from  the  third  dorsal  to  the  second  lumbar  spinal  roots.  These 
are  in  relation  with  the  gastro-intestinal  tract  by  sympathetic  afferent 
fibers.  A  similar  eruption  appears  if  the  ganglion  be  secondarily  in- 
volved in  any   inflammatory   or  destructive   process,   and  injury  to  a 


HERPES  ZOSTER. 


325 


nerve-trunk  may  also  cause  a  herpetic  eruption  limited  to  its  cutaneous 
distribution.  Zoster  sometimes  occurs  in  connection  witli  malaria,^ 
typhoid,  meningitis,  and  pneumonia,  and  after  arsenical,  carbonic  oxid 
gas,  and  intestinal  poisonings.  Second  attacks  are  so  rare  as  to  lend 
support  to  the  idea  that  immunity  is  aiForded  by  the  first  invasion. 
Herpes  zoster  is  also  frequent  in  tabes  and  paretic  dementia,  both  of 
which  coniiiionlv  involve  root  ganfflia. 

Pathology. — Barensprung  first  found  that  zoster  was  associated 
with  inflammatory  changes  in  the  nerve  and  ganglia.  Head  and  Camp- 
bell 2  have  placed  the  matter  on  a  secure  foundation.  In  all  well- 
examined  cases  an  acute  inflammatory  condition  is  found  in  the  ganglion 
with  V)loody  extravasation,  destruction  of  cells  and  fibers,  and  inflam- 
mation of  the  sheath.  These  are  followed  by  acute  degeneration  of 
greater  or  less  amount  and  even  by  secondary  sclerosis.  In  the  per- 
ipheral nerves  degeneration 
appears  and  disappears  or 
may  terminate  in  sclerosis 
jyari  passu  with  the  change 
in  the  ganglion.  The  nerve 
changes  are  secondary  to 
the  ganglionic  invasion,  but 
an  active  hemorrhagic  in- 
flammation may  extend  into 
the  nerve  from  the  ganglion. 
The  spinal  cord  presents 
acute  degeneration  of  the 
root  fibers  in  the  posterior 
column,  appearing  about  the 
tenth  day  of  the  disease. 
The  vesicles  of  the  skin 
eruption  contain  a  sterile 
serum,  and  no  evidence  of 
bacterial  invasion  is  found  in 
the  neighboring  profoundly 
inflamed  lymphatics. 

The  disease  may  be  considered  as  analogous  to  poliomyelitis  anterior 
acuta,  and  the  authors  quoted  have  proposed  for  it  the  name  acute 
posterior  j^oliomyelitis. 

Symptoms. — Zoster  furnishes,  according  to  Max  Joseph,  ^  about 
one  per  cent,  of  all  so-called  skin  diseases,  attacks  both  sexes  equally 
and  mainly  between  the  ages  of  fifteen  and  thirty  years.  Both  sides 
of  the  body  are  affected  with  equal  frequency,  but  bilateral  herpes 
zoster  is  extremely  rare.  There  is  an  old  superstition  that  should 
shingles  entirely  girdle  the  body  it  would  be  fatal.  As  a  matter  of 
fact,  bilateral  herpes  zoster  is  usually  due  to  serious  disease  of  the 
vertebral  column  such  as  cancer  or  destructive  Pott's  disease.  Epidemics 
of  zoster  occur  in  the  spring  and  autumn,  but  sporadic  cases  appear 

1  Winfield,  "  N.  Y.  Med.  Jour.,"  Auo;.  2,  1902.  -  "Brain,"  Dec,  1900. 

3  "Phila.  Med.  Jour.,"  Oct.  25,  1902. 


Fig.  118.— Herpes  zoster  confined  to  the  iifth  and  sixth  dorsal 
cord  segments  (v.  H.  Mareu). 


326 


DISEASES  OF  SPINAL  MENINGES  AND  SPINAL  NERVES. 


with  regularity  throughout  the  year.  There  is  a  prodromal  period  of  a 
few  days  with  malaise  and  slight  temperature.  Pains,  sometimes  in- 
tensely neuralgic,  burning,  discomfort,  uneasiness  in  varying  degree,  are 
felt  in  the  part  and  suddenly  the  eruption  appears.  Commonly,  pain 
and  temperature  then  subside  and  the  eruption  runs  its  indicated  course. 
Not  infrequently,  from  infection  of  the  eruption  by  various  applications 
or  the  fingers,  sloughs  and  even  gangrene  may  result,  but  ordinarily  under 
any  cleanly  management  the  blebs  dry  up  and  no  serious  scarring  results. 
The  distribution  of  zoster  is  peculiar  and  significant.  On  the  head 
and  face  it  follows  the  distribution  of  the  three  main  branches  of  the 
fifth  nerve  very  closely  in  some  instances  and  rarely  invades  the  fields 
of  two  of  them  in  one  patient.  More  commonly  it  is  confined  to  a  patch 
within  the  territory  of  a  single  branch  and  located  at  the  so-called  max- 
imal point  of  the  segmental  area 
outlined  by  Head  (see  page  59). 
On  the  trunk  the  eruption  is 
either  massed  about  the  maximal 
points  of  pain  in  the  segmental 
areas  related  to  the  spinal  cord, 
or,  as  in  the  case  illustrated,  fol- 
lows the  limits  of  such  area  pre- 
cisely. When  occurring  on  the 
extremities,  the  eruption  follows 
the  longitudinal  lines  of  the  cord 
segments.  The  eruption  does  not 
follow  peripheral  nerves  and  their 
cutaneous  distribution  unless  aris- 
ing from  injuries  or  inflammation 
of  such  nerves. 

Diagnosis. — The  diagnosis 
is  very  readily  made,  only  vesic- 
ular eczema  and  simple  herpes 
are  likely  to  be  confounded  with 
it.  The  course  of  the  malady 
will  clear  the  problem  as  well  as  the  anatomical  relations  of  zoster  which 
are  not  presented  by  eczema.  Herpes  occurring  after  arsenic  and 
carbonic  oxid  gas  poisoning  and  herpes  associated  -  with  pneumonia, 
meningitis,  malaria,  and  typhoid  present  identical  changes  in  the 
ganglia,  nerves,  and  skin.i  In  these  forms  the  girdle  distribution  is 
not  pronounced,  and  the  skin  eruption  tends  to  be  symmetrical,  though 
typical  zoster  may  be  encountered  in  these  associations. 

Herpes  simplex,  affecting  the  lips  and  nose  in  coryza  and  gastro- 
intestinal intoxications,  and  herpes  genitalis  are  still  unclassified  as  to 
the  participation  of  the  root  ganglia. 

Treatment. — The  treatment  seems  comparatively  unimportant.  An 
antiseptic  local  dressing,  preferably  a  dry  one,  a  free  action  of  the 
bowels,  and  the  elimination  of  any  discoverable  toxic  or  infectious 
element  are  the  indications. 

1  Howard,  "  Amer.  Jour.  Med.  Sciences,"  Feb.,  1903. 


Fig.  119.— Herpes   zoster  confined  to  tlie  fiftli  and 
sixth  dorsal  cord  segments  (v.  H.  JNJaren). 


PART  "V. 

DISEASES  OF  THE  CORD  PROPER 


CHAPTER   I. 
LOCALIZATION, 


Anatomical  Considerations. — The  spinal  cord  reaches  from  the 
foramen  magnum  to  the  lower  border  of  the  body  of  the  first  lumbar 
vertebra.  From  its  lower  portion  the  lumbar  and  sacral  nerve-roots 
extend  to  their  several  intervertebral  foramina  and  make  up  the  cauda 
equina,  which  occupies  the  dural  sheath  from  the  lumbar  enlargement 
of  the  cord  to  the  bottom  of  the  sacral  canal.  The  relations  of  the 
cord  to  the  surface  of  the  body  and  to  the  vertebral  bodies  and  the 
spinous  processes  are  shown  in  figures  120  and  121. 

The  cord  is  to  be  considered  as  made  up  of  a  number  of  similar  and 
partly  independent  segments  corresponding  to  the  vertebral  bodies,  and 
each  bearing  a  pair  of  spinal  nerves.  In  addition  it  furnishes  a  longi- 
tudinal pathway  for  afferent  and  efferent  nervous  impulses.  In  early 
fetal  life  these  cord-segments  are  in  apposition  with  their  corresponding 
v^ertebrge,  but  become  gradually  displaced  upward  as  the  sjoinal  column 
■outgrows  the  cord.  At  birth  the  lower  end  of  the  cord  is  opposite  the 
third  lumbar  body.  The  nerve-roots,  as  a  result  of  the  unequal  verti- 
cal growth  of  the  cord  and  spine,  become  progressively  longer  from  top 
to  bottom,  and  in  the  same  way  the  spinal-cord  segment  occupies  a  posi- 
tion relatively  higher  than  its  vertebral  centrum.  In  the  cervical  region 
this  amounts  to  the  height  of  about  one  vertebral  body,  and  in  the  dor- 
sal region  to  about  one  and  a  half  vertebral  bodies.  The  five  lumbar, 
five  sacral,  and  one  or  two  coccygeal  segments  are  crowded  into  the  lum- 
bar enlargement  below  the  upper  level  of  the  eleventh  dorsal  and  above 
the  second  lumbar  vertebral  body. 

In  estimating  the  position  of  the  various  vertebral  bodies  we  are 
guided  by  the  subcutaneous  tips  of  the  spinous  processes.  It  will  be 
recalled  that  these  have  a  downward  direction  in  the  cen^ical  and  dorsal 
region  and  overlap  the  body  of  the  vertebra  below.  Thus  the  tip  of 
the  eighth  dorsal  spine  is  on  a  level  with  the  ninth  dorsal  body.  Refer- 
ence to  figure  121  will  make  this  clear.  It  follows  that  the  exit  of  the 
spinal  root  at  the  intervertebral  foramen  has  only  a  relative  relation  to 

327 


328 


DISEASES  OF  THE  CORD  PROPER. 


the  cord-segment  from  which  it  originates.     Cord-lesions,  are,  therefore, 

always  above  the  level  of  their  spinal-nerve 
symptoms. 

Every  spinal-cord  segment  possesses  motor, 
sensory,  and  reflex  functions  besides  vasomotor, 
visceral,  and  trophic  activities.  These  are  re- 
lated to  corresponding  body-segments,  which 
are  shown  in  their  cutaneous  extent  in  figures 
17  and  20.  Their  relation  to  the  viscera  has 
already  been  indicated  (see  p.  57). 


')'  2 ' 


y6K. 


r  ','?' 


10' 


ftC 


11^' 


hhV 


'\    \' 


a2 


"S'i 


T^, 


Fig.   121. 


-Showing  tlie   relation  of   the  spinal  cord   to   the  body 
surlace 


Fig.  120. — The  numerals  in- 
dicate the  relations  of  the  verte- 
bral bodies  and  spines  to  the 
corresponding  spinal  segments 
of  the  cord. 


Cross-sections  of  the  cord  show  that  the 
gray  and  white  matter  vary  in  proportionate 
area  and  outline  at  different  levels  (Fig.  123). 
The  white  matter  is  divided  into  numerous 
zones  and  tracts.  One  division  is  based  on 
the  embryological  development  of  the  various 
tracts  (Fig.  124).  From  dissections,  physio- 
logical experiments,  and  especially  from  the 
results  of  morbid  processes,  we  have  still  further 
division   of  the   tracts.     These   are   shown    in_ 


LOCALIZATION. 


329 


figure  125  for  the  ascending  degenerations  which  follow  complete  divi- 
sion of  the  cord,  and  for  the  descending  degenerations  after  similar  lesions. 

The  H -shaped  cross-section  of  the  gray  matter  shows  numerous  cell- 
bodies.  Of  these  the  anterior  cornual  groups  are  the  best  understood 
and  contain  the  cell-bodies  of  the  lower  motor  neuron  throue^h  wiiich 
motor^  trophic,  and  vasomotor  iniiueuces  are  exercised  over  the  muscles, 
bones,  and  skin.  The  central  canal  is  situated  in  the  gray  commissure. 
The  essential  elements  of  the  cord  are  supported  by  fibrous  tissue  which 
is  continuous  with  the  penetrating  septa  of  the  pia  mater. 

The  circulation  in  the  cord  is  one  of  its  most  important  anatomical 
features.  Many  of  the  cord  diseases  are  due  to  vascular  lesions  or 
infections,  and  both  their  vertical  distribution  and  lateral  outlines  in 
transverse  sections  mav  be  limited  to  the  corresponding  arterial  fields. 


''olu/nn  efltssaiur 


Fig.  122. — Cross-section  of  cervical  spinal  cord,  showing  ite  anatomical  subdivisions  (Schaefer). 


The  arterial  supply  of  the  cord  consists  of  two  systems,  anterior  and 
posterior.  The  anterior  spinal  artery,  arising  within  the  skull  by  two 
roots  from  the  vertebrals,  extends  the  entire  length  of  the  cord  at  the 
anterior  fissure  (Fig.  127).  It  is  reinforced  by  branches  from  the  inter- 
costal, lumbar,  and  sacral  arteries,  which  follow  the  corresponding  nerves 
into  the  spinal  canal  and  accompany  the  nerve-roots  to  the  cord.  The 
anterior  spinal  artery  gives  off  about  three  hundred  branches,  called 
anterior  median  arteries,  which  penetrate  the  anterior  fissure  at  a  right 
angle  to  the  parent  stem.  At  the  commissure  they  enter  the  cord  and 
without  dividing  turn  toward  the  right  or  left  anterior  horn.  At  the 
neck  of  the  horn  the  artery  divides  into  an  anterior  branch  to  the 
anterior  horn  and  a  posterior  branch  which  is  distributed  to  the  neck 
and  to  a  portion  of  the  posterior  horn.     A  branch  is  also  given  off  in  a 


330 


DISEASES  OF  THE   CORD   PROPER. 


C  1 


C  8 


L  1 


C  2 


D  1 


L  3 


C  4 


D  2 


L  5 


C  5 


D  5 


Sac  2 


C  6 


D  8 


Sac  i 


C  7 


D  12 


^ 


t^J 


Co 


Fig.  123. — Transverse  sections  of  the  cord  at  various  levels,  to  show  the  relative  variations  in  gray  and 

white  matter. 


Fig.  124.— Divisions  of  the  cross-section  of  the  cord  based  on  Flechsig's  study  of  their  development. 
A,  Direct  pyramidal  tract ;  B,  fundamental  fasciculus  of  the  anterior  column  ;  C,  rest  of  lateral  column. 
J),  direct  cerebellar  tract ;  E,  crossed  pyramidal  tract;  F,  lateral  limiting  zone;  G,  anterior  root  zone; 
H,  middle  root  zone;  /,  median  zone;"  J,  column  of  Goll ;  K,  postero-intemal  root  zone;  L,  postero- 
external root  zone  or  zone  of  Lissauer  (Marie). 


Fig.  125.— Scheme  showing  secondary  degenerations.  Ascending  dtgenerations :  1,  Fibers  of  the 
.ascending  sulcomarginal  fasciculus;  b,  Gowers,  tract ;  7,  direct  cerebellar  tract ;  8,  cornucommissural 
tract ;  9,  column  of  Burdach  ;  10,  the  external  root  zone  tract ;  11,  zone  of  Lissauer ;  12,  column  of  Goll. 
Descending  degenerations:  2,  Descending  sulcomarginal  tract;  3,  direct  pyramidal  tract ;  6,  crossed 
pyramidal  tract;  13,  comma-shaped  tract  of  Schultze  (Marie). 

331 


332 


DISEASES  OF  THE  COED  PROPER. 

1 


Fig.  126.— 1,  Section  of  the  cord  showing  division  into  three  arterial  districts  (diagrammatic).  Part 
supplied  only  by  the  anterior  median  and  its  branches  is  shaded  with  parallel  lines.  Part  supplied  only 
by  the  peripheral  arteries  is  shaded  with  dots.  Part  supplied  by  both  systems  of  arteries  is  unshaded. 
2,  Transverse  section  of  cord  showing  distribution  of  anterior  and  posterior  arteries  (modified  after 
Marie).  Part  supplied  by  posterior  arterial  system  shaded  with  dots.  Part  supplied  by  anterior  system 
unshaded  (Williamson). 

AS 


Fig.  127. — Arteries  of  the  spinal  cord.  A  S,  Anterior  spinal ;  A  M,  anterior  median;  cc,  commis- 
sural ;  aa,  anastomotic ;  «  c,  anterior  central ;  p,  posterior  central ;  a  r,  anterior  root  arteries  ;  a'l,  anterior 
lateral ;  m  I,  median  lateral ;  p  I,  posterior  lateral ;  p  r,  posterior  root  artery  ;  p  c,  posterior  cornual ;  p  i, 
intermediate  septal;  p  m,  posterior  median  (modified  after  Obersteiner). 


LOCALIZATION. 


333 


vertical  direction  communicating  with  the  next  similar  artery,  and  forming 
a  longitudinal  chain  in  the  gray  matter  (Fig.  128).  The  anterior  spinal 
artery,  from  its  lateral  ramifications  on  the  surface  of  the  cord,  also  sup- 
plies the  white  matter  in  the  periphery  of  the  ventral  half  of  the  cord. 

The  posterior  arterial  system  of  the  cord  supplies  its  dorsal  half. 
The  two  posterior  spinal  arteries  arise  separately  from  the  vertebrals 
and,  coursing  around  the  medulla,  extend  the  entire  length  of  the 
cord  just  outside  the  posterior  nerve-roots.  Like  the  anterior  spinal 
artery,  they  receive  numerous  supply  branches  from  the  intercostal 
and  lumbar  arteries.  They  give  off  anastomotic  branches  wliich  unite 
"with  those  of  the  anterior  system 
on  the  surface  of  the  cord,  and  also 
present  a  chain  of  anastomosing 
branches  on  the  posterior  median  line 
of  the  cord.  From  these  branches 
small  twigs  penetrate  the  cord  supply- 
ing the  gray  matter  of  a  portion  of  the 
posterior  horn  and  the  posterior  half  of 
the  white  matter  of  the  cord  (Figs.  127 
and  128).  The  arterial  twigs  entering 
the  cord  are  of  the  terminal  variety, 
and  therefore  do  not  anastomose.  The 
territories  of  the  two  systems  are  not 
entirely  independent,  as  the  borders 
of  their  irrigation  fields  overlap  and 
the  adjacent  white  and  gray  matter 
receive  arteries  from  both  sources. 
Three  arterial  districts  are  thus  con- 
stituted :  (1)  That  supplied  only  by 
the  anterior  system  ;  (2)  that  supplied 
only  by  the  posterior  system,  and  (3) 
that  irrigated  by  both  systems  (Fig. 
126). 

It  will  be  apparent  from  these  facts 
that  arterial  disease  may  induce  lesions 
in  the  posterior  half  of  the  cord,  or  in 
the  anterior  half.  Further,  the  in- 
fection or  obliteration  of  a  single  an- 
terior median  artery  will  practically 
destroy  the  corresponding  anterior  horn. 

The  circulation  in  the  cord,  as  a  whole,  presents  some  mechanical 
conditions  that  are  significant.  The  spinal  arteries  are  the  longest  of 
their  size  in  the  body,  and,  owing  to  their  course,  are  not  subject  to  the 
direct  impact  of  cardiac  impulses.  In  this  respect  they  are  very  differ- 
ent from  those  of  the  brain.  Arterial  pressure  is  also  slight,  and  the 
venous  outlet  into  the  plexuses  about  the  dura  is  not  an  advantageous 
one  in  the  erect  position.  Gravity  impedes  the  return  circulation  as 
well  as  the  supply.  This  is  most  marked  at  the  lower  end  of  the  cord. 
The  long  course  the  lumbar  and  sacral  arteries  have  to  pursue  in  an 


Fig.  128. — Scheme  to  show  eireulatioa 
in  cord  segments  and  in  vertical  directions 
(Brissaud). 


334  DISEASES  OF  THE  CORD  PEOPER. 

upward  direction  along  the  corresponding  nerve-roots  in  the  cauda  still 
further  reduces  the  circulatory  qualifications  of  this  end  of  the  cord. 

The  arteries  in  the  cord  are  provided  with  perivascular  lymph- 
sheaths,  which  are  continuous  with  the  arachnoid  meningeal  spaces. 
Venae  comitantes  accompany  the  arterial  branches  and  empty  into 
posterior  and  anterior  plexiform  venous  chains  on  the  surface  of  the 
cord,  discharging  in  turn  into  the  extradural  plexuses.  Regurgitation 
from  the  extradural  veins  is  probably  impossible. 

The  jwsterior  roots  bear  a  ganglionic  enlargement  situated  just  out- 
side the  dura,  except  on  the  lowest  pairs,  where  it  is  within  the  sheath. 
Its  function  is  trophic  for  the  afferent  tracts  in  the  cord. 

Vertical  Localization  of  a  Cord-lesion. — Cord-lesions  are  irrita- 
tive or  destructive  and  are  manifested  by  corresponding  symptoms  in  the 
periphery  to  which  the  injured  cord-segments  are  anatomically  related 
and  to  which  their  peripheral  nerves  are  distributed.  Irritative  lesions 
are  marked  by  sensory  exaggeration,  such  as  hyperesthesia  and  pain,  by 
cramps  and  increased  reflexes.  Anesthesia,  paralysis,  and  abolished 
reflexes  result  from  destruction  of  a  cord-segment.  Trophic  loss  and 
vasomotor  paralysis  may  also  ensue,  but  become  apparent  at  a  later  date. 
The  symptoms  of  a  cord-lesion  embrace:  (1)  Those  due  to  the  derangement 
of  the  injured  segment ;  (2)  those  resulting  from  disturbances  in  the  con- 
duction attributes  of  the  cord,  and  (3)  those  arising  from  the  secondary 
degenerations  in  the  cord.  These  are  variously  combined,  depending 
upon  the  extent  of  the  lesion  in  the  cross-section  of  the  cord  and  its  age. 

Motor  Symptoms. — A  completely  disabling  injury  falHng  upon  any 
cord-segment  produces  paralysis  in  the  muscles  supplied  by  that  segment. 
It  will  be  noticed,  in  the  following  table,  that  muscular  actions  are  func- 
tionally grouj^ed  in  the  cord  and  extend  in  a  vertical  direction  through 
several  segments.  Single  muscles  are,  therefore,  practically  never  alone 
paralyzed  by  spinal  lesions.  Such  a  circumscribed  palsy,  or  one  confined 
to  a  group  of  muscles  supplied  by  a  single  nerve-trunk,  at  once  declares 
the  peripheral  character  of  the  lesion.  Xot  only  are  the  muscles  sup- 
plied by  the  injured  segment  paralyzed,  but  all  muscles  represented  in  the 
cord  below  the  lesion  are  withdrawn  from  voluntary  control  through  the 
division  of  their  motor  paths  in  the  upper  neurons,  which  traverse  the 
cross-lesion  by  way  of  the  pyramidal  tracts.    A  paraplegia  is  thus  induced. 

If  the  lesion  is  not  a  destructive  one,  but  irritative  in  its  effects, 
spasms  and  rigidity  may  be  present.  These  are  usually  attended  by 
clonus  in  the  large  muscles  whose  tendons  pass  over  joints ;  they  are 
present  in  all  the  levels  below  the  upper  limit  of  the  lesion,  but  more 
especially  in  the  lower  limljs. 

In  late  cases  of  partial  cross-lesions  the  rigidity  and  spastic  features 
are  well  developed.  The  lower  limbs  are  held  rigidly  extended  or,  less 
frequently,  sharply  flexed.  Any  attempt  to  move  them  causes  clonic 
trembling,  which  may  finally  end  in  a  sharp  pulling  up  of  the  leg  with 
a  '' jack-knife  "-like  jerk,  or  the  thighs  may  be  held  so  rigidly  by  the 
muscles  of  the  pelvic  girdle  that  if  one  limb  is  raised  from  the  bed 
by  the  foot  the  other  follows  with  it.  Contractures  finally  develop  : 
(1)  By  the  paralysis  of  one  group  of  muscles  and  the  unopposed  over- 


LOCALIZATION. 


335 


action  of  antagonists  ;  or  (2)  by  the  overirritation  of  the  motor  mechanism 
of  certain  muscles  or  muscle-groups  ;  or  (3)  by  structural  changes  in  the 
muscles,  causing  a  tendinofibrosis,  with  its  characteristic  retraction.  Only 
when  dealing  with  the  third  form  is  tenotomy  permanently  useful,  as 
in  the  other  varieties  the  activity  of  the  muscular  masses  promptly  re- 
produces the  conditions  sought  to  be  relieved.  In  the  structural  variety 
the  distorted  joint  usually  has  a  certain  limited  range  of  free  motion, 
but  is  then  abruptly  stopped  by  the  retracted,  unyielding  tendons,  which 
stand  out  prominently.  On  the  other  hand,  the  muscular  contractures,  due 
to  overstimulation  in  which  fibroid  changes  have  not  taken  place,  usually 
yield  slowly  or,  perhaps,  jerkily  to  efforts  tending  to  extend  them. 


Motor  and  Eeflex  Functioks  of  the  Spinal-coed  Segments 
(after  Starr  and  Edinger). 


Segment. 

Muscles. 

Reflexes. 

Cervical         | 

1 

Sternomastoid. 
Trapezius. 

2-3      - 

Scaleui. 

Small  rotators  of  head. 

r 

Diaphragm. 

Lev.  ang.  scap. 

Dilatation,  of  pupil  by  irritating 

side 

Rhomboids. 

of  neck,  4-7  cervical. 

4^    1 

Spinati. 
Deltoid. 

Supinat.  long. 

Scapular  reflexes,  5  C-l  D. 

5   [■- 

Biceps. 

Supinat.  long.,  5  C. 

Supinat.  brev. 

Serrat.  mag. 

Pectoralis  (clav.) 

Biceps,  5-6  C. 

Teres  minor. 

6 

1 

Pronators. 

Posterior  wrist,  6-8  C. 

Brachialis  ant. 

Triceps. 

Long    extensors  of  wrist   and 

Anterior  wrist,  7-8  C. 

7      - 

fingers. 

^ 

Pectoralis  (costal). 

Latiss.  dorsi. 

Palmar,  7  C-l  D. 

Teres  maj. 

f 

L    Long  flexors,  wrist  and  fingers. 

Epigastric,  4-7  D. 

8  j    , 

Extensors  of  thumb. 

Dorsal  1   ( 

L    Intrinsic  hand-muscles. 

Abdominal,  7-11  D. 

2-12 

Dorsal  and  abdominal  muscles. 

Lumbar 

Abdominal  muscles. 

Cremaster,  1-3  L. 

1    '  ^ 

I    Iliacus. 

Psoas. 

Patellar,  2-4  L. 

2  - 

Sartorius. 
Flexors  of  knee. 

Bladder,  2-4  L. 

I 

r    Quad,  femoris. 

3      - 

,    Int.  rotators  of  thigh. 

r 

L    Adductors  of  thigh. 

Eectal,  4  L.-2  S. 

1 

4  - 

Abductors  of  thigh. 

'  Tibialis  ant. 

Gluteal,  4-.  5  L. 

r   Calf-muscles. 

5 

1  Ex.  rotators  of  thigh. 
Extensors  of  toes. 

Achilles,  .5  L. 

Sacral 
1-2 

l^    Perouei. 

f    Long  flex,  of  toes. 

\    Intrinsic  foot-mnscles. 

Plantar.  1-2  S. 
Anal,     \o_5s 

3-5 

Perineal  muscles. 

Virile,  j  ^  ^  ^• 

336  DISEASES  OF  THE   COED  PROPER. 

Sensory  Symptoms. — A  cross-lesion  destroys  cutaneous  sensation  in 
the  segmental  area  corresponding  to  the  lesion  and  in  all  parts  below, 
the  first  directly,  the  second  by  interruption  of  conduction.  The  dis- 
tribution of  anesthesia  is  practically  the  best  guide  to  the  upper  level  of 
the  lesion.  In  the  diagrams  shown  on  pages  55  and  58  it  will  be  seen 
that  the  cutaneous  areas  of  the  skin  do  not  correspond  exactly  to  the 
cutaneous  distribution  of  the  spinal  nerves.  This  variation  will  often 
serve  to  differentiate  between  a  cord-lesion  and  one  of  the  nerve-roots. 
Root-lesions  cause  areas  of  sensory  disturbances  that  coincide  with  the 
cutaneous  distribution  of  the  nerves  arising  from  them.  In  the  trunk, 
for  instance,  division  of  the  cord  produces  an  anesthesia  whose  upper 
level  is  practically  in  a  horizontal  plane,  while  root-lesion  anesthesia  or 
hyperalgesia  follows  the  intercostal  nerves  and  spaces.  The  territories 
supplied  by  the  intercostal  nerves  overlap  decidedly,  so  that  destruction 
of  a  single  nerve  may  manifest  no  sensory  loss.  It  requires  that  at  least 
two  should  be  divided  to  produce  an  anesthetic  patch  or  belt. 

The  upper  border  of  a  spinal  lesion  is  usually  further  indicated  by  a 
zone  of  hyperesthesia  due  to  the  irritant  action  of  the  lesion  on  sensory 
paths  within  the  cord  or  upon  the  posterior  nerve-roots.  This  is  described 
by  the  patient  as  a  band  or  girdle-like  sensation  about  the  trunk  and  as 
tightness  in  the  limbs.  Its  vertical  extent  corresponds  to  the  irritating 
influence,  but  rarely  does  it  exceed  two  segmental  areas.  A  light  touch 
in  this  hypersensitive  zone  causes  a  feeling  as  of  pins  and  needles,  of 
pricking,  of  burning,  of  tingling,  or  of  a  thrill,  and  is  not  a  pure  exaggera- 
tion of  sensation,  but  a  perversion  of  it.  Very  severe  pain  is  usually 
absent  in  pure  cord  lesions,  but  the  girdling  sensation  is  often  described  as 
painful ;  and  if  the  posterior  roots  are  injured,  as  in  Pott's  disease  or 
through  meningeal  inflammation,  the  pains  are  intense,  and  often  darting 
in  character.  Spontaneous  sensations  are  frequent,  and  patients  often 
attempt  to  describe  peculiar  feelings  of  an  unnatural  sort  which  they 
may  locate  in  areas  that  are  absolutely  insensitive  to  external  stimulation. 
They  may  be  caused  by  the  irritation  of  the  conduction  tracts  at  the 
upper  level  of  the  lesion,  and  are  then  referred  to  the  peripheral  sites 
from  which  they  would  naturally  arise. 

In  lesions  of  lesser  degree  sensation  may  not  be  much  affected,  even 
when  motion  is  abolished,  or  the  general  sense  of  touch  may  be  broken  up 
so  that  temperature  and  painful  impressions  are  not  recognized.  Tactile 
impressions,  in  the  same  way,  may  fail  to  arouse  the  sensorium  when  more 
energetic  and  painful  impressions  still  traverse  the  injured  pathways. 

The  reflexes  furnish  very  valuable  evidence  not  only  as  to  the 
upper  level  of  the  cord  lesion,  but  sometimes  as  to  its  vertical  ex- 
tent. The  cord  lesion  that  destroys  the  portion  of  a  reflex  arc  within 
the  cord  obliterates  that  reflex  but  does  not  abolish  the  reflexes  below 
its  own  level  unless  the  cord  is  entirely  and  completely  divided.  It  is 
now  fairly  well  established  that  complete  division  of  the  cord  in  man 
extinguishes  all  cord  reflexes  below  that  level.  On  the  contrary,  if  the 
division  is  incomplete,  the  lower  reflexes  may  at  first  be  enfeebled,  but 
within  a  few  weeks  show  much  exaggeration.  In  a  case  showing  such 
increased  reflexes  the  absence  of  one  or  more  at  a  given  level  points  to 
the  diseased  portion  of  the  cord.     Again,  the  upper  level  of  abolished 


LOCALIZATION.  337 

reflexes  usually  coincides  with  that  of  anesthesia,  and  both  focalize  the 
lesion.  In  other  cases  the  extension  and  invasion  of  cord  disease  may 
be  traced  by  the  successive  disappearance  of  spinal  reflexes ;  its  reces- 
sion, by  their  reappearance. 

Trophic  Conditions. — As  the  trophic  centers  for  muscles  correspond 
with  their  motor  spinal  centers  in  the  anterior  horns,  a  lesion  which 
destroys  this  portion  of  the  gray  matter  of  a  cord's  segment  induces  atrophy 
in  the  related  muscles.  This  atrophy,  like  the  palsy  arising  from  a 
cord  lesion,  has  a  functional  distribution  that  depends  upon  the  associa- 
tion of  muscular  representation  in  the  cord.  By  reference  to  the  table, 
page  335,  it  is  evident  that  all  of  a  large  muscle  need  not  be  involved, 
and  tliat  groups  of  muscles  innervated  by  different  nerve  trunks,  but 
centrally  associated,  may  be  thus  selected.  The  extent  of  the  wasting 
is  limited  by  the  vertical  dimensions  of  the  lesion.  The  muscles  inner- 
vated from  the  cord  above  and  below  the  destructive  process  are  spared, 
and  retain  their  nutritional  supply  and  their  electrical  responses. 
The  wasted  muscles  lose  tone  early,  and  shortly  thereafter  present  the 
electrical  reaction  of  degeneration.  Atrophic  loss  is  best  seen  in  the 
muscles  of  the  extremities  ;  next  in  those  of  the  shoulder  and  pelvic  gir- 
dles. In  the  thoracic  and  abdominal  regions  the  wasting  is  only  per- 
ceptible when  several  adjacent  cord  segments  are  diseased. 

Slight  atrophic  disturbances  appear  in  the  skin,  analogous  to  those  in 
neuritis  and  confined  to  the  area  related  to  the  iiijured  cord  segments. 
In  the  case  of  irritative  lesions,  such  as  acute  myelitis  and  cord  hemor- 
rhage, the  dystrophic  condition  may  be  acute  and  intense.  Under  the 
incitement  of  comparatively  slight  pressure  or  other  superficial  irrita- 
tion, herpetoid  eruptions  and  acute  bedsores  form  in  a  few  hours. 
These  occur  over  the  sacrum,  heels,  malleoli,  and  trochanters  by 
preference,  but  may  occur  wherever  the  bones  are  subcutaneous  and 
the  trophic  control  disturbed.  The  use  of  counterirritation  in  the  mild- 
est form,  and  even  of  frictions  with  the  hand,  may  provoke  them.  Hot 
bottles  that  would  otherwise  cause  no  injury  may,  under  these  circum- 
stances, induce  most  serious  local  effects  and  deep  destruction  of  tissue. 

Vasomotor  disturbance  in  some  degree  is  usually  present,  and 
•consists,  ordinarily,  at  first  of  a  tendency  to  vascular  dilatation  and 
increased  warmth.  The  so-called  tache  cerebrate  is  easily  provoked 
I)elow  the  lesion.  In  cases  of  long  standing  the  skin  is  livid  and  cold, 
frequently  with  increased  perspiration.  Lesions  in  the  cervical  region 
■often  cause  flushing  and  perspiration  on  the  side  of  the  neck  and  face, 
and  may  reduce  the  heart-beats  to  forty  or  even  to  twenty  a  minute. 
Dorsal  lesions,  on  the  other  hand,  are  sometimes  attended  by  a  persist- 
ently rapid  pulse.  These  vasomotor  disturbances  are  frequently  at- 
tended by  an  increase  of  body  temperature  in  lesions  in  the  upper 
•dorsal  and  lower  cervical  regions,  but  it  is  often  difficult  to  exclude 
pyrexia,  due  to  the  infectious  nature  of  the  disease  or  to  intestinal  or 
vesical  disturbance  resulting  from  it. 

Visceral  symptoms  are  usually  not  pronounced,  but  the  secretions 
in  the  alimentary  canal  and  its  muscular  activity  are  frequently  dis- 
turbed. Constipation  is  the  rule,  and  fermentation  of  the  stomach  and 
intestinal  contents,  with  gaseous  disturbance,  is  very  common.  Vomit- 
22 


338  DISEASES  OF  THE  COED  PROPER. 

ing  and  difficulty  in  swallowing  occur  in  lesions  of  the  cervical  cord. 
The  anal  and  vesical  sphincters  are  usually  disturbed.  When  the 
lesion  involves  their  reflex  centers  in  the  lumbar  cord,  complete  relaxa- 
tion and  incontinence  ensue ;  but  if  the  lesion  is  above  their  spinal 
centers,  voluntary  control  alone  is  lost.  They  then  act  automatically, 
and  the  corresponding  viscera  are  unconsciously  evacuated  at  intervals. 
The  examining  finger  readily  provokes  the  anal  sphincteric  contraction 
in  this  condition,  which  is  not  the  case  if  its  center  is  destroyed. 
There  is  a  tendency  to  fecal  and  urinary  retention,  dependent,  in  part, 
upon  the  lack  of  power  in  the  abdominal  muscles.  In  the  case  of  the 
bladder  this  leads  to  distention  by  increased  residuum  and  weakening 
of  the  detrusor,  and  the  dilatation  of  the  viscus  may  become  extreme. 
The  result  is  usually  a  cystitis,  which  is  often  precipitated  by  the  use 
of  a  septic  catheter.  Damage  to  the  kidneys  arises  both  from  the 
back-pressure  of  urine  and  the  propagation  of  inflammation  up  the 
ureters.  The  table  of  symptoms  in  disabling  but  not  absolutely  destruc- 
tive transverse  cord  lesions  (see  pages  339-345)  is  based  upon  the 
exhaustive  work  of  Wichman.  ^  If  the  entire  cross-section  is  absolutely 
destroyed,  the  symptomatology  is  the  same  excepting  that  there  is  com- 
plete absence  of  muscle  reflexes  below  the  lesion. 

Horizontal  Localization  of  a  Cord  Lesion. — Many  spinal  cord 
lesions  are  more  or  less  circumscribed  in  transverse  area,  and  give  rise 
to  widely  different  symptoms  as  they  aifect  the  various  physiological 
divisions  of  the  cord.  Some  cord  diseases  are  symmetrical,  and  both 
sides  of  the  transverse  section  show  identical  conditions.  Others  are 
unilateral,  and  the  two  sides  show  different  states,  not  only  at  the  level 
of  the  lesion,  but  also  in  the  levels  aifected  by  the  secondary  ascending 
and  descending  degenerations. 

Lesions  of  the  pyramidal  tracts  produce  motor  paralysis  below  the 
level  afifected  and  induce  a  spastic  condition  in  the  paralyzed  area, 
marked  by  increased  muscle  tonus,  exaggerated  reflexes,  rigidity,  and 
contractures.     These  tracts  degenerate  downward. 

Disease  of  the  posterior  columns  is  marked  by  sensor}^  disturbance, 
especially  of  those  elements  of  touch  related  to  pressure  and  to  the 
muscle  and  joint  sensations.  Ataxia  results.  The  temperature  and 
pain  sensations  are  also  usually  diminished,  and  all  forms  of  cutaneous 
impressions  are  delayed  in  reaching  the  brain.  The  muscle  reflexes, 
especially  the  deep  tendon  reflexes,  are  abolished  or  greatly  diminished. 
An  upward  degeneration  in  the  postero-internal  column  ensues. 

AVhen  the  anterior  horn  is  affected  motor  paralysis  occurs,  but  only 
in  the  muscles  which  are  supplied  by  the  large  cells  actually  involved 
in  the  morbid  focus.  The  mucles  also  atrophy.  If  the  process  is 
acute,  paralysis  takes  place  at  once  and  atrophy  gradually  develops.  In 
very  insidious  lesions  paresis  and  atrophy  develop  at  an  equal  pace,  and 
fibrillary  twitchings  are  usually  present.  Reflexes  are  abolished  by 
lesions  of  the  anterior  horns  and  vasomotor  paralysis  is  induced  in  the 
field  related  to  the  cornual  disease.  Dea^eneration  descends  the  lower 
neurons  arising  from  the  diseased  portion  of  the  cord,  and  the  reaction 
of  degeneration  is  presented  in  nerve  and  muscle. 

'  "Die  Ruckenmarksnerven  und  ihre  Segmentbeziige, "  Berlin,  1900. 


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346 


DISEASES  OF  THE   COED  PROPER. 


Disease  of  \he ])osterior  horn  is  marked  by  sensory  disturbance  or  anes- 
thesia in  a  given  area,  such  as  follows  a  lesion  of  the  posterior  column. 

Lesions  of  the  posterior  roots  cause  anesthesia  if  complete  ;  hyperal- 
gesia and  radiating  pain  if  irritative. 

Lesions  of  the  anterior  roots  produce  the  same  results  as  lesions  of 
the  anterior  horns. 

Lesions  arising  within  or  immediately  about  the  central  canal,  as  in 
syrmgomyelia,  produce  a  peculiar  dissociation  of  touch  sensations,  so 
that  painful  and  thermal  impressions  are  not  properly  recognized  while 
tactile  or  contact  impressions  remain  practically  unaffected.  Joint 
dystrophies  are  often  added. 

A  lesion  that  divides  one  lateral  half  of  the  cord  gives  rise  to  the 
Brown-Sequard  syndrome  (see  p.  55). 

In  many  cord  diseases  two  or  more  physiological  divisions  are  sym- 
metrically affected.  In  amyotrophic  lateral  sclerosis  we  have,  added  to 
the  rigidity,  myotatic  irritability,  and  contractures  that  mark  disease  of 
the  lateral  tracts,  a  progressive  muscular  atrophy  that  is  due  to  the 
lesion  of  the  anterior  horns.  Ataxic  paraplegia  is  marked  by  symp- 
toms in  both  the  lateral  tracts  and  the  posterior  columns,  and  we  find 
ataxia  and  rigidity  with  weakness  variously  combined.  The  following 
table  roughly  shows  the  relation  of  the  various  cord  diseases  to  the  physi- 
ological division  of  the  cord.  Those  which  are  marked  by  lesions  con- 
fined principally  to  given  tracts  in  the  spinal  cord  are  denominated 
system  diseases,  as  distinguished  from  indiscriminate  lesions.  As  will 
appear  in  the  consideration  of  individual  diseases,  some  of  these  cord 
lesions,  as  in  locomotor  ataxia,  are  only  a  part  of  the  morbid  findings. 


'  Indiscrimi- 
nate lesions.  " 


Organic  dis- 
eases  of 
the  cord. 


System  dis- 
eases. 


Hemorrhage. 

Myelitis. 

Softening. 

Insular  sclerosis. 

Tumors. 

Traumatic  injury. 

Compression  from  hone  disease  and  tumors. 


Lesions  of 
single  tracts. 


Comhined 
lesions. 


Anterior  cornu. 


Lateral  tract. 


Posterior  col- 
umns. 

Anterior  cornu 
and  lateral 
tract. 


Lateral  and  pos- 
terior    col-  -J 


Poliomyelitis  acxita. 
Progressive   muscu- 
lar atrophy. 

f  Primary     lateral 
sclerosis. 
(Little's      disease.) 
L  Lathy  rism. 

(  Locomotor  ataxia. 
\  Ergotism. 


Amyotrophic  lateral 

sclerosis. 

Ataxic  paraplegia. 
Friedreich's  ataxia. 
Heredocerehellar 
ataxia. 


Pellagra. 
Eesuits      of 
lesions. 


cross 


LOCALIZATION. 


347 


Lesions  of  the  Cauda  Equina. — The  descending  roots  of  the 
lumbar,  the  sacral,  and  tlie  coccygeal  nerves  make  up  the  cauda,  which 
occupies  the  dural  sheath  below  the  upper  level  of  the  second  lumbar 
vertebra — a  distance  of  about  ten  inches.  As  the  roots  are  given 
off  in  lateral  pairs,  the  upper  ones  are  external  and  soonest  pass  into 
the  vertebral  foramina.  Those  that  are  longest,  therefore,  are  situated 
toward  the  middle  line.  It  is  evident  that  a  lesion  involving  the  dural 
contents  below  the  conus  meduUaris  will  produce  a  root  lesion.  This 
may  be  partial  or  complete,  and  varies  according  to  the  level 
which  it  occupies  and  the  roots  actually  involved.  The  longer  roots 
are  usually  most  affected,  even  when  the  lesion  is  so  placed  as  to 
embrace  all  the  roots  of  the  cauda  extending  below  the  conus.  As 
a  consequence,  the  nerves  arising  from  the  lowest  cord  segments  and 
distributed  to  the  lowest  body  levels  are 
the  ones  commonly  disturbed.  The  paral- 
ysis, anesthesia,  abolition  of  reflex  action, 
and  atrophy  that  result  from  a  complete 
root  division  correspond  to  the  peripheral 
distribution  of  the  injured  nerve  roots. 
These  peripheral  distribution  areas  corre- 
spond somewhat  to  the  segmental  cord  areas, 
but  show  a  marked  tendency  to  follow  the 
distribution  of  the  nerve  trunks  (Figs.  15 
and  16).  Both  sides  of  the  body  are  usually 
affected,  but  uniform  symmetry  is  the  ex- 
ception while  in  cord  lesions  it  is  the  rule. 

The  motor,  sensory,  trophic,  and  reflex 
disturbance  that  results  from  a  complete 
division  of  the  caudal  roots  is  the  same 
in  character  that  follows  nerve-trunk  divi- 
sion. In  lesions  of  less  destructive  char- 
acter sensation  may  exceptionally  be  but 
slightly  disturbed  when  motion  is  quite 
abolished.  Increased  reflexes  are  not  en- 
countered. Complete  and  permanent  loss 
of  rectal  and  bladder  reflexes  points  to  in- 
volvement of  the  cord. 

In  lesions  of  the  cauda,  therefore,  we  have  anatomically  coextensive 
sensory,  motor,  trophic,  and  reflex  symptoms,  corresponding  to  the  dis- 
tribution of  the  roots  making  up  the  sacral  and  lumbar  plexuses  or  a 
part  of  them.  The  disturbance  always  affects  the  lowest  portion  and 
ceases  at  some  definite  upper  level.  Most  cord  lesions,  on  the  other 
hand,  are  limited  in  vertical  extent,  and  the  reflex  and  trophic  disorders 
are  confined  to  the  corresponding  body  segments. 

The  usual  lesions  which  affect  the  cauda  are  vertebral  fractures  and 
dislocations,  new  growths,  penetrating  wounds,  and  hemorrhage.  In 
tabes  and  multiple  neuritis,  which  are  sometimes  confounded  with 
caudal  disease,  symptoms  are  present  at  higher  levels,  as  in  the  upper 
extremities,  and  in  the  pupillary  reflexes.  Injury  to  the  plexuses  within 
the  pelvis  usually — at  least,  at  first — produces  unilateral  symptoms. 


Fig.  129. — Area  of  anesthesia  in 
a  lesion  of  the  cauda,  afifecting  all 
the  sacral  roots. 


348  DISEASES  OF  THE  CORD   PROPER. 


CHAPTER  II. 
INDISCRIMINATE  CORD  LESIONS. 

TRAUMATIC  LESIONS  OF  THE  CORD  SUBSTANCE. 

The  spinal  cord  is  sometimes  reached  by  penetrating  wounds  made 
by  knife,  bullet,  or  other  foreign  object.  It  is  injured  more  frequently 
by  the  displacement  of  vertebrae,  and  this  is  almost  invariably  attended 
by  both  fracture  and  dislocation.  With  the  surgical  conditions  we  shall 
not  deal.  It  is  to  be  noted  that  vertebral  fracture-dislocations  are  fre- 
quently devoid  of  any  external  signs  of  displacement,  even  when  it  is 
found  postmortem  that  the  vertebral  bodies  have  been  so  completely 
displaced  as  to  actually  shear  the  cord  in'  two.  Restitution  to  a  practi- 
cally normal  position  may  occur  at  once,  either  spontaneously  or  due  to 
the  lifting  eiforts  of  those  who  first  attend  the  injured  person.  These 
cases  all  furnish  a  history  of  trauma,  and  usually  present  local  evidence 
of  it.  The  question  that  arises  regards  the  location  and  extent  of  the 
lesion  in  the  cord.  This  must  be  determined  by  an  application  of  the 
considerations  set  forth  in  the  foregoing  chapter. 

The  prognosis  in  a  case  of  actual  injury  to  the  cord  substance  is 
always  grave  and  generally  fatal.  If  the  lesion  cause  complete  divi- 
sion, there  can  be  no  hope  for  voluntary  control  or  sensory  improvement 
below  its  level.  Only  in  very  slight  injuries  from  dislocation  of  the 
vertebrae  or  from  pressure  due  to  meningeal  hemorrhage  can  much  be 
expected.  In  such  a  case  complete  paralysis  may  pass  away ;  but  when 
the  reflexes  are  completely  abolished  in  the  paraplegic  area  after  the 
first  week,  little  improvement  need  be  expected.  Some  degree  of  dis- 
ability always  persists,  and  commonly  bedsores,  cystitis,  kidney  and  pul- 
monary complications  carry  oflP  the  patient  after  a  lingering  helplessness. 

HEMORRHAGE  INTO  THE  CORD  (HEMATOMYELIA). 

Hemorrhage  into  the  spinal  cord  is  not  an  extremely  rare  accident. 
It  occurs  under  a  variety  of  circumstances,  and  is  punctate  and  multiple 
or  single  and  more  or  less  extensive.  There  is  also  a  so-called  perforat- 
ing form  simply  due  to  the  tendency  of  the  extravasated  blood  to  follow 
the  lines  of  least  resistance  in  the  longitudinal  direction  of  the  cord. 

Etiolog-y. — Hemorrhage  into  the  cord,  like  spinal  meningeal  hem- 
orrhage, with  which  it  is  frequently  associated,  may  follow  severe  spinal 
concussions  and  violent  wrenchings  of  the  back.  Excessive  muscular 
effort,  as  in  lifting,  has  caused  it,  and  Gowers  reports  this  accident 
following  repeated  coitus.  A  focus  of  myelitic  softening  is  frequently 
the  seat  of  hemorrhage,  and  hemorrhage,  in  turn,  is  followed  by  a  zone 
of  myelic  softening.  It  is  often  difficult  to  tell  which  process  was  the 
initial  one.  In  some  cases  of  caisson  disease,  or  divers'  palsy,  hemorrhage 
has  been  found  due  to  the  too  sudden  reduction  of  the  high  atmospheric 
pressure  under  which  such  work  is  done.     Continued  convulsions,  as  in 


INDISCRIMINATE  CORD  LESIONS.  349 

status  epilepticus,  intense  chorea,  tetanus,  and  asphyxia,  may  produce 
punctate  hemorrliages  and  hemorrhagic  infiltration,  especially  in  the 
gray  matter  of  the  cord.  Purpura  and  sudden  cessation  of  habitual 
hemorrhages,  such  as  that  from  piles  and  menstruation,  may  provoke  a 
cord-apoplexy.  A  dilated  central  canal  and  teratological  defects  and 
fissures  in  the  cord  predispose  to  it.  Changes  in  the  arterial  coats  are 
much  less  active  factors  than  in  cerebral  hemorrhagic  apoplexy,  as 
atheroma  and  miliary  aneurysmal  dilatations  are  of  the  greatest  rarity 
in  the  cord.  The  arterial  pressure  conditions  and  the  direct  cardiac 
impulse  that  plav  so  large  a  part  in  brain-lesions  are  also  absent. 

Morbid  Anatomy. — In  the  punctate  and  infiltrating  variety  the 
cord  may  merely  appear  slightly  reddened,  or  small,  pinhead  clots  may 
be  found,  particularly  in  the  gray  matter.  They  usually  first  occupy 
the  perivascular  spaces  and,  aside  from  traumatic  cases,  are  secondary 
to  myelitic  softening.  The  appearance  varies  with  the  size  of  the  extrava- 
sation.    The  large   single  or  focal  hemorrhage  also  finds  its  usual  seat 


\     ~ 


Fig.  130. — Hemorrhage  into  the  gray  matter  of  the  cervical  cord  below  the  centers  for  the  biceps,  and 
supinator  longus  ;  paralysis  and  atrophy  of  the  triceps  and  extensors  of  wrists  and  fingers. 

in  the  gray  matter,  less  commonly  in  the  central  canal  or  in  a  congenital 
fissure  of  the  cord.  It  is  usually  ovoid  in  shape,  ^vith  the  long  axis 
vertical,  and  may  perforate  the  yielding  gray  substance  of  the  cord  for 
several  inches  in  extreme  cases.  It  causes  a  fusiform,  dark-colored 
swelling  of  the  cord.  The  blood  usually  comes  from  the  larger  median 
arteries  or  from  those  entering  the  anterior  horn  by  the  anterior  roots, 
and  favors  the  gray  matter  as  a  situation.  In  rare  instances  the  blood 
may  break  through  the  white  columns  and  even  appear  to  a  slight  ex- 
tent in  the  membranes.  Meningeal  clots  are  also  commonly  present  in 
traumatic  cases.  Around  the  clot,  after  a  few  days,  the  cord  shows  a 
zone  of  softening.  In  cases  of  long  standing  the  clot  may  undergo 
changes  similar  to  those  in  the  brain,  and  a  hemorrhagic  cyst  remains, 
with  ascending  and  descending  degenerations  corresponding  to  the  loca- 
tion of  the  lesion  in  the  cross-section.  A  wide  area  of  myelitis,  con- 
taining a  comparatively  small  and  recent  clot  or  hemorrhage  into  a 
gliomatous  growth,  may  be  encountered  as  secondary  accidents. 


350  DISEASES  OF  THE  COED  PROPER. 

Symptoms. — A  primary  focal  hemorrhage  into  the  cord  is  of  rapid, 
usually  of  sudden  onset.  The  infiltration  sort,  being  almost  always  sec- 
ondary, may  be  preceded  by  sensory  and  motor  symptoms  for  hours, 
days,  and  even  weeks.  This  is  also  true  of  the  larger  clot  that  forms 
in  a  softened  myelitic  territory,  producing  sudden  exacerbation  of  the 
usually  precedent  paraplegic  symptoms.  The  earliest  symptom  is  com- 
monly one  of  severe  pains  radiating  in  the  body-segments  correspond- 
ing to  the  hemorrhagic  focus.  These  are  due,  presumably,  to  the  pressure 
or  laceration  of  the  sensory  tracts  in  or  near  the  posterior  commissure. 
Darting  pains  occur  in  the  limbs,  girdling  pains  in  the  trunk  that  may 
be  mistaken  for  angina  pectoris  and  intestinal  or  vesical  colic.  Very 
shortly — that  is,  in  the  course  of  a  few  minutes  or  an  hour — after  an  acci- 
dent has  occurred,  and  the  patient  has  perhaps  w^alked  a  short  distance, 
'paraplegic  symptoms  appear.  These  may  be  partially  unilateral  at 
first.  The  legs  weaken,  the  patient  gradually  or  quickly  sinks 
down,  and  usually  the  motor  loss  is  promptly  established  at  its 
maximum.  The  condition  that  now  develops  depends  on  the 
location,  extent,  and  size  of  the  clot,  and  the  amount  of  pressure  it 
brings  to  bear  on  the  conduction  tracts.  Usually  there  is  some  im- 
provement, owing  to  the  subsidence  of  the  pressure  and  of  the  shock 
or  insult  to  the  adjacent  portions  of  the  cord.  The  development 
after  a  day  or  two  of  myelitic  softening  or  myelitis,  with  elevation  of 
the  body-heat,  usually  again  emphasizes  the  paraplegia,  and  thereafter 
the  course  of  the  disease  and  its  treatment  is  that  of  myelitis.  The 
bladder  and  anal  sphincters  are  commonly  immediately  relaxed.  All 
the  tendon  reflexes  are  diminished  at  first,  but  after  a  week  or  ten  days 
they  begin  to  increase,  and  comport  themselves  as  in  the  spastic  state 
that  follows  an  incomplete  cross-lesion  of  the  cord.  Early  in  the  attack 
spasms  and  tonic  convulsions  in  the  muscles  supplied  by  the  affected 
segments  and  those  below  the  lesion  are  frequently  met  with. 

The  diagnosis  is  often  difficult  and  it  is  frequently  impossible  to 
exclude  a  meningeal  hemorrhage.  Preceding  sensory,  motor,  and  tem- 
perature disturbances  indicate  a  primary  myelitis.  Only  in  those  cases 
where  the  temperature  is  normal,  the  onset  abrupt,  and  the  pain  of  the 
segmental  variety,  can  a  definite  diagnosis  be  ventured. 

The  prognosis  depends  upon  the  location  of  the  lesion.  Hemor- 
rhage into  the  cord  in  the  upper  cervical  region  is  almost  certainly 
fatal,  and  is  worse  in  the  cervical  and  lumbar  enlargements  than  in  the 
dorsal  region.  The  secondary  myelitis  may  extend  upward  and  cause 
death,  or  downward  and  involve  the  lower  levels.  Only  when  sensa- 
tion improves,  motor  gain  is  apparent,  and  febrile  disturbance  is  passed, 
is  the  patient  safe.  Some  lasting  local  paralysis,  wasting,  and  trophic 
disturbance  result,  and  more  or  less  permanent  spasticity  remains.  Too 
often  bedsore,  cystitis,  sepsis,  or  other  complications  carry  oif  the  patient. 

Treatment. — The  immediate  treatment  of  the  hemorrhage  consists 
of  measures  to  check  it.  The  patient  should  be  placed  face  downward 
with  the  spine  elevated  as  much  as  possible,  and  applications  of  ice  or 
ice-bags  made  over  the  length  of  the  cord.  Absolute  quiet  and  the 
determination  of  blood  to  the  surface,  intestinal  tract,  and  extremities 


INDISCRIMIXATE   COED  LESIONS.  351 

should  be  favored.  The  ai'terial  tension  may  be  reduced  by  minim  doses 
of  tincture  of  aconite  or  veratruni  viride  every  hour,  but  the  use  of  ergot 
is  not  advised.      After  the  first  day  the  treatment  is  that  of  myelitis. 

THROMBOTIC  SOFTENING  OF  THE  CORD. 

Thrombosis  of  the  arteries  of  the  spinal  cord  undoubtedly  occurs. 
The  anatomical  features  of  the  circulation  in  the  spinal  cord  render 
this  accident  a  very  likely  one.  The  long  course  the  arterial  supply 
traverses,  especially  in  the  lumbar  cord,  produces  a  sluggishness  of  its 
current  that  favors  the  deposition  of  fibrin  if  at  the  same  time  the 
arterial  wall  is  nutritionally  disturbed.  As  the  spinal  arteries  after  en- 
tering the  cord  are  of  the  terminal  variety,  it  is  evident  that  their  oblit- 
eration will  result  in  the  softening  of  their  irrigation  fields.  This  result 
has  ordinarily  been  confounded  with  myelitis  and  clinically  presents  the 
same  picture.  Gowers  denies  its  occurrence,  as  does  Striimpell,  but  in 
syphilitic  cases  this  mechanism  is  demonstrated  by  such  cases  as  are 
described  by  AYilliamsoni  and  those  of  Schmaus,  Sottas,  Dej6rine,  and 
Knapp  quoted  by  him.  Lloyd  ^  also  refers  to  such  an  one  in  his  own 
experience.  Biernacki  ^  reports  three  cases  in  full,  two  of  which  were 
syphilitic.  Embolism,  on  the  other  hand,  can  practically  be  excluded, 
owing  to  the  narrowness  of  the  spinal  vessels,  the  long  and  tortuous 
course  they  pursue,  and  the  slowness  of  the  blood-stream.  Experiment- 
ally, however,  by  the  injection  of  inert  powders  into  the  circulation  of 
lower  animals  it  has  been  produced  by  Lamy,^  Singer, ^  and  others. 
Thougli  atheroma  is  infrequent  in  the  spinal  circulation,  syphilitic  cases 
commonly  show  endo-arterial  and  peri-arterial  changes.  The  same  are 
likely  to  occur  in  infectious  diseases  and  in  many  blood  states,  and 
favor  thrombosis. 

The  softened  area  resulting  from  thrombotic  occlusion  of  the  supply- 
ing artery,  just  as  in  the  brain,  is  likely  to  become  hemorrhagic  through 
the  venous  back-pressure,  and,  therefore,  may  present  any  degree  of 
hemic  discoloration.  Into  it  a  neighboring  blood-vessel  may  rupture, 
with  hemorrhagic  results.  As  the  symptoms,  treatment,  and  prognosis 
are  those  of  myelitis,  it  is  not  necessary  to  repeat  them  here. 

MYELITIS. 

Under  the  term  myelitis  a  host  of  spinal  lesions  have  been  grouped 
which  have  in  common  the  appearance  of  a  local  softening,  with  more 
or  less  inflammatory  disturbance.  Inflammation  of  the  cord-substance 
is  probably  never  a  primary  process.  Infection  may  readily  reach  the 
cord  by  the  vascular  supply.  That  it  does  so  is  evident  in  the  inflam- 
matory lesions  of  the  cord-substance  that  so  often  follow  the  exanthe- 
mata and  septicemic  diseases  generally. 

The  term  myelitis  is  a  generic  one.  In  this  chapter  we  are  dealing 
with  the  indiscriminate  lesions  of  the  cord-substance,  and,  therefore,  re- 
serve for  separate  consideration  the  variety  of  myelitis  known  as  acute 
anterior  poliomyelitis  that  singles  out  the  anterior  gray  matter,  is  largely 

^^  "  Eelation  of  Diseases  of  the  Spinal  Cord  to  the  Spinal  Blood-vessels,"  London, 
1895.  2  "Xervous  Diseases,"  by  American  Authors,  Philadelphia,  1895. 

3  "Dent.  Zeit.  f.  Nervenheilk.,"  Bd.  x. ' 
*  "Archives  de  Xeurologie,"  1894.  =  "  Deut.  Zeit.  f.  Heilk.,"  Bd.  xvii,  1897. 


352  DISEASES  OF  THE   CORD  PEOFEB. 

confined  to  it,  and  presents  a  distinct  clinical  type.  AVe  may  distinguish 
a  transi-ersemyeWth,  one  that  is  disseminated,  and  a  centra/ form  depend- 
ing merely  upon  the  accidental  location  of  the  lesion  or  lesions  in  the 
cord.  Of  these,  acute  transverse  myelitis  may  be  taken  as  a  t}^pe,  and  is 
the  one  commonly  encountered. 

Btiolog-y. — Acute  myelitis  may  follow  icounds  of  the  cord,  lacera- 
tions of  its  substance,  from  hemorrhage,  or  from  fracture-dislocations  of 
the  veitebrse.  It  has  followed  violent  muscular  efforts,  spinal  concussions, 
and  falls  on  the  back,  but  in  such  cases  minute  myelitic  hemorrhage  or 
other  structural  lesion  may  have  introduced  the  program.  It  has  been 
repeatedly  attributed  to  cold  and  exposure,  and  this  assertion  has  been 
handed  down  so  persistently  that  it  seems  a  permanent  fixture  in  the 
literature.  If  cold  plays  any  part,  it  is,  as  in  pneumonia,  to  favor  the 
introduction  of  infection.  Compression  of  the  cord  by  disease  of  the 
spine  or  the  meninges,  or  by  new  growths,  causes  a  localized  softening 
which  may  girdle  the  cord.  The  association  of  myelitis  and  menin- 
gitis is  shown  in  the  condition  of  meningomyelitis  already  described. 
The  extension  of  the  inflammatory  process  to  the  cord  is  a  clearly  recog- 
nized feature  of  most  meningeal  infections.  It  may  follow  all  the  acute 
infectious  diseases  ;  probably  by  an  initial  thrombosis.  Sy2:)hilis  frequentlv 
leads  to  it,  and  usually  by  a  thrombotic  process.  It  may  also  result 
from  a  gummy  tumor  or  from  syphilitic  meningitis.  These  will  be 
considered  more  at  length  in  the  chapter  on  Syphilis  of  the  jSTervous 
System.  Influenza,  gonorrhea,  all  infectious  and  pyemic  conditions,  and 
caisson  disease  have  caused  it. 

Morbid  Anatomy. — On  inspection  an  inflamed  cord  presents  a  red, 
swollen  appearance  and  a  reduced  consistency  that  may  make  it  pulta- 
ceous  and  even  diffluent.  The  vertical  dimensions  of  the  softening  var^' 
from  one-half  an  inch  to  several  inches,  and  usually  embrace  the  full 
thickness  of  the  cord.  Depending  upon  the  amount  of  extravasated 
blood  and  the  age  of  the  lesion,  the  myelitic  portion  is  red,  yellowish,  or 
white.  It  is  usually  difficult  or  impossible  to  distinguish  the  gray  from 
the  white  portions  of  the  cross-section,  and  commonly  the  softening  is  so 
great  that  the  cord  breaks  down  under  the  slightest  handling.  All  details 
are  then  obliterated.  Microscopically,  there  is  more  or  less  disintegration 
of  the  cord-elements.  There  is  usually  present  an  abundance  of  phago- 
cytic elements,  and  amyloid  bodies  are  frequently  encountered.  The  axis- 
cylinders  are  destroyed,  or  divided  or  granular.  Sometimes  a  few  of 
them  appear  much  swollen.  The  nerve-cells  participate  in  the  destruc- 
tion, and  those  that  are  recognizable  appear  swollen,  pigmented,  gran- 
ular, filled  with  fat-globules,  or  vacuolated.  Their  processes  early  dis- 
appear. The  vessels  are  altered,  their  walls  thickened  ;  the  perivascular 
sheaths  are  dilated  with  cells,  detritus,  and  hemorrhage.  The  intersti- 
tial tissue  is  exaggerated  in  proportion  to  the  duration  and  intensity  of 
the  disease,  and  in  the  disseminated  form  of  myelitis  forms  islets  of 
thickened  tissue.  There  are  usually  many  spider-cells  present.  The 
meninges  are  variably  affected  by  extension  of  the  inflammation  to  them. 
In  cases  of  long  standing  the  cord  may  be  reduced  to  a  mere  fibrous 
shred. 


INDISCRIMINATE   CORD  LESIONS.  353 

If  the  lesion  has  been  of  sufficient  duration,  ascending  degenerations 
are  found  in  the  ])osterior  and  direct  cerebellar  columns,  and  descend- 
ing degeneration  in  the  pyramidal  tracts.  In  addition,  by  the  process 
of  contiguous  extension  the  myelitis  may  propagate  itself  in  either  direc- 
tion from  its  initial  focus  along  any  of  the  tracts  of  the  cord,  or  along 
its  gray  substance,  irrespective  of  the  direction  of  conduction  in  the 
physiological  pathways. 

In  disseminated  myelitis  small  foci  of  inflammation  are  scattered 
throughout  considerable  portions  of  the  cord,  presenting  the  same  mi- 
nute changes  as  outlined  above.  It  may  require  the  microscope  to  detect 
them,  or  they  may  be  manifest  as  small  red  or  hemorrhagic  points  in 
the  cross-section.  In  the  central  form  there  is  cellular  infiltration  about 
the  central  canal,  which  is  often  dilated  and  choked.  The  nerve-roots 
arising  from  the  focus  of  inflammation  show  neuritic  changes  and  de- 
generation, with  corresponding  muscle  changes.  Should  a  myelitis  be 
infectious  from  the  first,  or  subsequently  infected  by  pus-producing  bac- 
teria, abscess  formation  results.  From  such  a  cord-abscess  the  menin- 
ges may  become  infected  and  a  purulent  meningitis  ensue. 

Symptoms. — The  symptoms  of  myelitis  are  as  diverse  as  the  cases, 
and  each  case  varies  with  the  vertical  or  transverse  location  of  the 
lesion  or  lesions,  with  their  number,  extension,  severity,  and  character. 
The  onset  is  modified  by  the  initial  cause  of  the  disease  in  the  cord. 
When  hemorrhage  is  the  first  step,  it  is  apoplectic  in  suddenness. 
Traumatism  has  its  own  history.  The  infectious  diseases  have  their 
individual  clinical  features  upon  which  the  myelitis  is  grafted.  In  less 
well-marked  antecedent  states  the  onset  of  the  paraplegic  features  of  the 
disease  may  be  unheralded  by  any  subjective  or  objective  phenomena. 
A  few  days  of  malaise,  of  slight  fever,  or  of  fleeting  paresthesia  may 
indicate  the  systemic  condition  which  eventuates  in  myelitis.  In  other 
but  rare  instances  convulsions,  high  temperature,  and  rigors  declare  the 
toxic  process  and  usher  in  the  spinal  symptoms.  These  consist  usually 
atfirst  of  intense  j9«i«.s,  which  may  be  darting  in  character,  extending  along 
the  limbs  or  girdling  the  trunk.  There  is  more  or  less  tingling  and  numb- 
ness. The  distribution  of  such  sensory  disturbance  in  relation  to  the 
cord-segments  should  be  significant.  Shortly  after — in  a  few  minutes 
in  hemorrhagic  cases,  in  a  iew  hours  or  a  few  days  in  infectious  forms 
— more  or  less  paraplegic  weakness  is  developed,  which  involves  every- 
thing below  the  segmental  location  of  the  disease.  The  motor  loss 
may  be  sudden  or  gradual,  complete  or  partial,  but  usually  is  insidi- 
ous, progressive,  and  does  not  reach  an  absolute  degree.  The  control 
of  bladder  and  bowek  is  usually  disturbed  early,  with  more  or  less 
incontinence  or  retention.  In  some  instances  the  motor  features  come 
on  and  progress  with  the  sensory  disturbances,  or  even  precede  them. 
The  order  of  symptoms  depends  upon  the  portion  of  the  cord  first  and 
most  diseased  and  the  destructive  or  irritative  character  of  the  lesions. 
It  follows  that  spasmodic  twitching  of  the  limbs  may  occur,  but,  as  a 
rule,  tliere  is  complete  flaccidity  at  first. 

The  number  and  variability  of  the  symptoms  are  so  great  that  they 
can  best  be  presented  under  several  heads. 
23 


354  DISEASES  OF  TEE  COED  FEOPER. 

Sensation. — The  upper  level  of  the  sensory  disturbanee  is  usually- 
marked  by  a  hypersensitive  band  corresponding  to  the  U2:)per  segmental 
extent  of  the  cord-lesion,  and  due  to  its  irritant  action.  This  is  always 
present  in  cross-myelitis,  and  should  be  diligently  sought,  as  it  is  of  the 
greatest  localizing  importance.  In  the  entire  area  below  the  hyper- 
sensitive zone  sensation  is  more  or  less  blunted  and  may  be  completely 
lost  in  all  its  modes.  AVhen  the  cross-lesion  is  less  complete,  sensation 
or  motion,  or  both,  may  be  only  partially  involved.  When  the  lesion 
is  practically  central,  we  have  the  peculiar  dissociation  of  touch-sensa- 
tions that  marks  lesions  in  this  location.  There  is  analgesia  and  loss 
of  temperature  sense,  with  preservation  of  tactile  perceptions.  Involve- 
ment of  the  posterior  roots  and  extension  of  the  inflammation  to  the 
meninges  are  marked  by  local  pain  and  tenderness  over  the  spine  at  the 
level  of  the  lesion  and  above  it.  The  girdle  pain  has  the  same  topo- 
graphical significance  as  the  hypersensitive  zone,  and  usually  corresponds 
to  it.  The  patient  often  complains  of  paresthetic  sensations  below  the 
lesions,  even  in  completely  anesthetic  territory,  or  in  the  abdominal 
viscera.  These  may  be  misleading  to  both  patient  and  physician.  The 
greatest  care  must  be  exercised  in  testing  the  cutaneous  and  other  sense 
perceptions,  as  indicated  in  Part  I.  The  sensor}'  symptoms  frequently 
var}^  greatly  during  an  attack  unless  the  lesion  completely  severs  the 
cord.  The  reappearance  of  sensation  where  previously  wanting  is  a 
good  sign,  just  as  the  increase  of  sensory  loss  is  indicative  of  extension 
of  the  disease  and  of  bad  import,  sometimes  of  fatal  significance  if 
toward  the  upper  cervical  levels. 

Motion. — The  loss  of  motion  corresponds  to  the  same  segmental  distri- 
bution as  the  anesthesia,  and  may  be  complete  or  partial.  The  anterior 
gray  matter  in  the  inflammatory  focus  is  usually  completely  destroyed, 
or  at  least  its  functions  are  completely  inhibited  for  the  time.  The  mus- 
cles controlled  by  this  portion  of  the  cord  are  paralyzed.  The  amount 
and  degree  of  paralysis  below  the  lesion  depend  upon  the  completeness 
of  the  cross-lesion,  and  varies  within  wide  limits.  In  the  disseminated 
and  multiple  forms  of  inflammation  various  functionally  related  groups 
of  muscles  may  be  singled  out,  as  in  acute  poliomyelitis.  Here,  also, 
the  motor  loss  may  show  any  degree  of  incompleteness.  The  loss  of 
sphincter  control  is  usually  present  from  the  first  and  persistent.  When 
the  lumbar  cord  is  aflected,  incontinence  of  urine  and  distention  of  the 
bladder  and  bowels  follow  the  destruction  of  their  spinal  centers.  The 
distribution  of  the  paralysis  is,  therefore,  always  dependent  upon  the  seg- 
ment or  segments  of  the  cord  that  are  diseased,  and  has  a  common  ten- 
dencv  to  paraplegic  distribution,  involving  both  sides  more  or  less  sym- 
metricallv.  The  distribution  of  symptoms  in  rare  instances  suggests  the 
Brown-Sequard  syndrome,  due  to  a  lateral  hemicordal  division  (see  p.  55). 

Reflexes. — The  reflexes  whose  spinal  centers  are  situated  in  the 
inflammatory^  focus  are  abolished.  Below  that  level  they  are  usually 
diminished  at  first,  but  at  the  end  of  a  week  or  ten  days  commence  to 
increase  in  vigor  and  gradually  attain  extreme  exaggeration.  Should 
the  lesion  actually  divide  the  cord,  they  are  abolished,  as  in  traumatic 
cases,  but  the  preservation  of  a  very  few  fibers  in  any  portion  of  the 


INDISCRIMINATE   CORD   LESIONS.  355 

cord's  cross-section  seems  sufficient  to  allow  of  their  exaltation  and  the 
development  of  spasticity  and  rigidity.  All  forms  of  clonus  and  intensi- 
fication of  reflex  activity  may  be  encountered.  The  tendency  is  for  the 
lower  limbs  to  be  rigidly  extended,  adducted,  and  sometimes  crossed. 
Less  frequently  flexion  predominates  and  the  legs  are  flexed  upon  the 
thighs,  which  are  firmly  applied  along  the  anterior  surface  of  the  trunk. 
The  clonic  condition  of  the  limbs  sometimes  serves  to  jerk  them  about 
sharply  upon  slight  skin  friction,  even  by  the  removal  of  the  bedding 
or  any  gentle  manipulation.  The  flaccidity  of  the  early  days  is  replaced 
by  a  hypertonicity,  so  that  the  muscle-masses  may  stand  out  promi- 
nently. Contractures  may  result  and  often  do.  Priapism  is  commonly 
present  in  cervical  myelitis,  and  frequent  in  inflammation  of  the  dorsal 
cord,  but  absent  in  lumbar  involvement.  Lesions  in  the  cervical  region 
are  commonly  attended  by  a  dilated  pupil,  but  in  some  cases,  especially 
of  the  disseminate  variety,  optic  neuritis  is  present,  and  pupillary  re- 
sponses are  variously  modified.  The  condition  of  the  vesical  and  rectal 
reflexes  is  one  that  should  early  engage  attention.  If  the  lesion  involves 
the  lumbar  cord,  the  sphincters  are  usually  relaxed  and  incontinence  fol- 
lows, but  there  is  a  tendency  to  urinary  retention  through  relaxation  of  the 
visceral  walls,  and  cystitis  is  easily  established.  Again,  when  the  lesion 
is  above  the  lumbar  cord  the  sphincters  operate  automatically,  and  both 
feces  and  urine  are  discharged  at  intervals ;  but,  again,  the  bladder-wall 
is  likely  to  yield,  or  acts  ineffectually  without  the  aid  of  the  abdominal 
muscles ;  urine  is  retained,  becomes  ammoniacal,  and,  through  contami- 
nation by  catheter  or  otherwise,  cystitis  develops.  Rupture  of  the  blad- 
der through  distention  and  ulceration,  causing  peritonitis,  has  been  seen. 

Trophic  Chang-es. — The  muscles  that  are  anatomically  related  to 
the  diseased  cord-segment  waste  promptly  and  show  the  reaction 
of  degeneration.  In  addition  the  inert  limbs  lose  in  size  from  disuse 
and  considerable  emaciation  is  frequently  presented,  but  the  electrical 
changes  are  lacking  and  the  reflexes  are  usually  increased.  The  general 
vasomotor  and  trophic  conditions  below  the  lesion  are  disturbed.  A  slight 
stroke  of  the  finger-nail  upon  the  skin  will  usually  present  a  line  of 
persisting  vascular  stasis  like  the  meningeal  tache,  and  at  first  the 
paralyzed  portions  show  an  elevation  of  temperature  even  above  that  in 
the  mouth.  In  cases  of  long  standing  the  local  temperature  is  abased 
and  the  paralytic  members  are  blue,  cold,  cyanotic,  and  often  edematous. 
The  skin  is  often  dry,  harsh,  and  scaly,  and  readily  breaks  down  under 
pressure,  forming  ugly,  sluggish,  unmanageable  bedsores.  The  tend- 
ency to  bedsore  is  prominent  from  the  first,  and  it  is  in  these  cases  that 
the  sacrum  is  sometimes  denuded  within  a  few  days  under  the  continued 
influence  of  pressure,  irritation  from  urine  or  feces,  and  the  dystrophic 
element.  The  entire  vesical  mucous  lining  may  exfoliate  from  dis- 
turbed trophic  conditions.  Joint-lesions  of  the  arthropathic  sort  are 
rarely  induced. 

The  general  nutrition  of  the  patient  suffers  to  some  degree,  but  less 
than  would  be  expected,  and  it  can  usually  be  maintained  at  a  reason- 
able level.     The  danger  arises  from  extension  of  the  myelitis  and  from 


356  DISEASES  OF  THE   COED  PROPER. 

complications  arising  through  cystitis,  bedsore,  nephritis,  and  septicemia, 
or  concurrent  acute  infections,  such  as  pneumonia. 

Course. — Acute  cases  reach  their  maximum  in  a  few  days,  others 
in  a  few  weeks,  and  then,  if  death  does  not  result,  a  long  stationary 
period  or  one  of  gradual  improvement  or  decline  succeeds.  The  occur- 
rence of  an  extension  of  the  inflammation  may,  at  any  time,  jeopardize 
life  by  invading  the  respiratory  apparatus.  Acute  bedsore  is  always  a 
dangerous  complication,  and  cystitis  is  hardly  less  so.  When  spastic 
features  develop,  they  rarely  recede  to  any  considerable  extent,  and  imply 
permanent  disability  and  the  paraplegic  state.  Sensation  or  motion  may 
return  singlv.  The  localized  wasting  due  to  involvement  of  the  anterior 
gray  never  repairs,  and  adjacent  portions  of  the  gray  matter  may  subse- 
quently be  involved.      Death  may  take  place  early  from  cardiac  and 


/ 


Fig.  131. — Dystrophic  bedsores  over  trochanters  and  sacriiin  in  a  case  of  transverse  myelitis. 

respiratorv  failure  or  follow  at  any  period  from  exhaustion  due  to  the 
primary  infection  or  that  secondary  to  bedsore,  cystitis,  nephritis,  septi- 
cemia, or  is  caused  by  a  gradual  extinction  of  the  vital  energy.  The  cases 
that  recover  bear  the  indelible  marks  of  the  disease  in  weakened  and 
spastic  legs,  areas  of  anesthesia,  sphincteric  paresis,  and  local  atrophies 
variously  distributed  in  accordance  with  the  seat,  extent,  and  intensity 
of  the  cord-injury.  These  furnish  cases  of  so-called  chronic  myelitis, 
but  inflammation  has  subsided  and  the  conditions  presented  are  due  to 
the  degenerations  that  follow  the  primary  lesion.  They  are  more  fully 
described  under  the  head  of  The  Paraplegic  State. 

Diagnosis  in  myelitis  presents  numerous  problems  and  requires 
painstaking  examination  and  study.  AVe  have  to  ask  ourselves  :  (1) 
Whether  the  cord  is  actually  diseased ;  (2)  the  extent  of  that  disease — 
namely,  its  localization — and  (3)  its  origin.     Unless  there   is   loss  of 


INDISCRIMINATE   CORD  LESIONS.  357 

certain  groups  of  cord-functions  anatomically  related,  we  can  not  incrimi- 
nate the  cord.  Of  these,  the  most  important  are  early  loss  of  motion  of  a 
paraplegic  distribution  and  relaxation  of  the  sphincters.  Corresponding 
sensory  disturljance  or  anesthesia  surmounted  by  a  band  of  hyperes- 
thesia will  almost  surely  be  added  to,  if  it  does  not  precede,  the  motor 
loss.  The  onset  is  usually  acute^  and  in  the  hemorrhagic  variety  it  is 
sudden.  Extreme  pain  of  a  radiating,  segmental  variety  and  sudden 
onset  suggest  an  initial  vascular  lesion.  After  ten  days  we  may  detect 
muscular  atrophy  corresponding  to  the  lesion  and  usually  increased 
reflexes  below  the  lesion,  which  usher  in  the  spastic  stage  that  is  to  per- 
sist as  a  paraplegic  state  if  the  patient  survives.  Even  before  this  time 
the  loss  of  faradic  response  in  the  muscles  innervated  by  the  spinal  gray 
embraced  in  the  inflammatory  focus  may  indicate  the  myelitis  and  its 
vertical  extent.  To  the  further  localization  of  the  cord  disease  we  bring 
to  bear  the  considerations  set  forth  in  the  preceding  chapter.  Our  main 
early  guide  is  loss  of  reflexes  and  the  vertical  extent  of  such  hiatus  in 
the  chain  of  spinal  reflexes. 

In  poliomi/elitis  sensory  deficiency  is  not  present  and  the  motor  loss 
is  usually  of  monoplegic  outline.  In  laeningitis  we  have  the  early  and 
persistent  root  pain,  tenderness  over  the  spine,  and  retention  of  motion 
and  reflexes.  In  Landry's  palsi/,  or  acute  ascending  myelitis,  we  meet 
the  steady  advance  of  the  paraplegia  from  the  feet  and  legs  upward, 
with  undisturbed  sensation,  faradic  activity,  sphincteric  control,  and 
tendon  reflexes.  In  multiple  neuritis  the  slow  onset,  involvement  of  all 
four  extremities,  major  affection  of  the  extensors,  and  paresthesise  at 
the  distal  ends  of  the  limbs  are  significant.  In  hysteria  the  sensory 
disturbance  has  a  characteristic  outline,  the  reflexes  are  not  greatly  dis- 
turbed, trophic  changes  are  not  present,  and  hysterical  stigmata  are  ob- 
tainable. The  mistake  usually  made  is  to  overlook  an  organic  disease 
because  hysteria  is  also  present. 

The  diagnosis  of  myelitis  having  been  reached,  it  is  always  in  order 
to  question  its  origin.  This  may  be  evident  from  the  history  or 
presence  of  traumatism,  acute  infectious  disease,  septicemia,  sypliilis,  or 
other  cachectic  state. 

Prognosis  in  such  a  generic  condition  as  myelitis  must  be  based 
upon  general  rules  applied  to  the  individual  case.  The  outlook  is 
always  grave  as  to  life  and  positively  bad  as  to  complete  recovery.  If 
the  patient  is  not  carried  off  during  the  first  few  days  by  the  implication 
of  the  cardiorespiratory  apparatus,  or  by  the  overwhelming  systemic 
effect  of  the  infection,  which  is  perhaps  only  locally  manifest  in  the  cord, 
and  if  he  reaches  the  end  of  the  first  week  without  any  indications  of 
extension  of  the  myelitis,  he  may  be  considered  out  of  immediate  danger. 
If  at  the  end  of  three  or  four  weeks  he  does  not  show  at  least  some 
slight  return  of  motion  and  sensation,  it  is  not  likely  that  these  will 
ever  greatly  improve.  On  the  other  hand,  distinct  improvement  within 
the  first  two  or  three  weeks  is  usually  followed  by  rapidly  progressive 
gain  almost  to  the  point  of  entire  recovery.  AVhen  spasticity  appears 
it  implies  descending  degeneration  in  the  pyramidal  tracts  and  lasting- 
disability.      Cervical  myelitis  is  almost  invariably  fatal.      Involvement 


358  DISEASES   OF   TEE   CORD   PROPER. 

of  the  dorsal  cord  is  much  less  disastrous  than  when  the  lesion  invades 
the  lumbar  enlargement  and  perforce  permanently  cripples  the  sphincter 
control  and  the  legs.  Acute  bedsore  and  acute  cystitis  are  ominous 
complications.  Local  muscular  atrophies  are  subject  to  this  rule  :  If 
faradic  response  can  not  be  obtained  in  such  muscles  at  the  end  of  the 
iirst  two  weeks,  they  may  be  considered  as  permanently  impaired.  In 
syphilitic  cases  that  reach  a  marked  degree  of  paralysis  we  may  hope 
to  prevent  extension  of  the  disease  and  sometimes  to  secure  a  marked 
recession  of  the  paresis  but  never  for  complete  cure. 

Treatment  divides  itself  into  three  parts  :  (1)  That  of  the  causal 
condition ;  (2)  that  of  the  invasion  stage,  and  (-3)  that  of  the  paraplegic 
state.  Traumatic  conditions,  pressure  from  meningeal  hemorrhage  or 
new  growths  require  surgical  measures.  Any  systemic  infection  or 
infection  atrium  must  be  directly  dealt  with.  For  the  local  condition 
the  treatment  outlined  for  meningitis  is  available.  During  the  invasion 
period  the  inflamed  cord  should  be  kept  elevated  by  placing  the  patient 
in  the  prone  posture.  Local  applications  of  ice  are  useful.  Active 
cathartics  should  be  used  if  the  patient's  strength  warrant  their  admin- 
istration. Quiet,  and  above  all  cleanliness,  must  be  secured  and  local 
pressure  avoided.  Early  attention  to  the  bladder  is  usually  needed  but 
catheterization  is  only  indicated  when  vesical  retention  can  be  determined 
by  palpation  and  percussion,  and  then  must  be  carried  out  with  the  most 
scrupulous  antiseptic  precautions.  Febrile  disturbance  is  usually  a 
part  of  the  original  causal  process  and  to  be  met  accordinglv. 

After  the  first  two  or  three  days,  if  the  case  runs  on,  a  water  or  air 
bed  will  be  found  of  the  greatest  service  in  distributing  j)ressure.  The 
heels,  elbows,  and  other  bony  prominences  in  the  paralytic  field  should 
be  carefully  padded  with  cotton.  The  constant  use  of  a  bed  urinal 
will  often  help  to  keep  the  patient  dry.  Alimentation  and  sup- 
porting treatment  will  require  thoughtful  attention.  At  the  end  of 
a  week  careful  massage  and  faradization  may  be  employed,  if  not 
contraindicated  by  surgical  conditions  in  the  spine.  Gentle  frictions 
and  kneadings  of  the  muscles  are  indeed  advisable  from  the  first  day, 
and  the  position  of  the  paralyzed  limbs  should  be  changed  hourlv  if 
only  slightly,  as  is  automatically  done  in  healthy  sleep.  When  a  bed- 
sore develops,  its  best  management  depends  upon  keeping  it  perfectly 
dry.  To  this  end  a  soft  gauze  pad  and  an  abundance  of  pulverized 
boric  acid  should  be  used,  but  the  dressing  must  not  be  cumbersome  or 
so  arranged  as  to  exercise  pressure  and  the  patient's  position  must  also 
conform  to  this  requirement.  Cystitis  requires  careful,  thorough, 
skilful  catheterization  and  washing  out  of  the  bladder  every  eight  or 
twelve  hours.  The  administration  of  salol,  beta-naphtol,  or  urotropin 
also  tends  to  render  the  urine  uuirritating  and  to  some  extent  disinfects 
the  bowel  contents.  The  management  of  the  case  now  resolves  itself 
into  one  of  good  nursing  and  attention  to  obviate  complications,  espe- 
cially malposition  of  joints  and  contracture  deformities. 

As  motion  and  power  reappear  the  patient  should  be  encouraged  to 
use  the  limbs  intelligently.  By  concentrating  his  attention  upon  a 
certain  movement  he  can  often  produce  it  after  a  number  of  attempts. 


INDISCRIMINATE   CORD   LESIONS.  359 

Local  nutrition  must  be  kept  up  by  massage  and  electricity.  The  use  of 
the  f  aradic  brush  to  the  anesthetic  area  is  of  service  in  restoring  sensation. 
The  general  physical  condition  and  usual  constipation  require  constant 
attention. 

THE  PARAPLEGIC  STATE. 

The  paraplegic  state  is  the  usual  termination  of  a  myelitis  or  any  in- 
discriminate cord  lesion  that  does  not  end  fatally,  and  corresponds  in  some 
sense  to  the  "  hemiplegic  state "  that  supervenes  upon  brain-lesions. 
Very  often  arising  from  such  cause  as  acute  myelitis,  it  is  mistaken  for  a 
chronic  inflammatory  condition  and  denominated  chronic  myelitis  or  con- 
founded with  ataxic  paraplegia  and  even  with  locomotor  ataxia.  The 
descending  degeneration  in  the  pyramidal  tracts  is  a  consequence  of  any 
lesion  which  involves  the  upper  neuron  in  the  cord.  When  due  to  bi- 
lateral lesions  above  the  cord  it  is  best  called  a  diplegia.  Cross-lesions 
of  the  cervical  cord  are  usually  promptly  fatal,  so  that  the  paraplegic 
state  arising  from  indiscriminate  lesions  only  reaches  its  later  and 
■characteristic  development  in  cord  lesions  below  that  level. 

Etiolog-y. — All  the  indiscriminate  cord  lesions,  such  as  traumatism, 
liemorrhage,  thrombotic  softening,  myelitis,  tumors,  and  pressure  from 
meningeal  and  spinal  diseases  and  growths,  give  rise  to  a  paraplegia 
which  is  more  or  less  pronounced  in  proportion  to  the  extent  of  the 
lesion.  In  addition,  the  so-called  system  lesions  which  are  marked  by 
sclerotic  degeneration  of  the  lateral  tracts  produce  paraplegic  conditions, 
but  without  distinct  anesthesia.  We  find  it  also  in  Little's  disease, 
ataxic  paraplegia,  family  cerebellar  ataxia,  and  amyotrophic  lateral 
sclerosis.  The  only  common  fact  is  the  degeneration  of  the  motor  tracts 
in  the  lateral  columns.  Diseases  of  the  upper  neuron  arising  from  intra- 
cranial lesions  have  been  considered  in  connection  with  diseases  of  the 
brain  (Part  III). 

Symptoms. — The  symptoms  of  this  secondary  state  vary  greatly 
and  are  dependent  upon  the  nature,  extent,  and  activity  of  the  initial 
lesion.  In  the  system  diseases  the  spastic  paraplegia,  as  in  Little's  dis- 
ease, may  be  really  a  diplegia  from  embryonic  defect,  and  congeni- 
tally  present.  In  the  family  ataxias  the  defect  is  also  teratological, 
but  the  symptomatic  development  is  postnatal  and  usually  insidious. 
Ataxic  paraplegia  and  amyotrophic  lateral  sclerosis  also  develop  very 
gradually  and  usually  in  adult  life.  They  all  in  common  possess  defects 
of  the  pyramidal  tracts  marked  by  loss  of  muscular  control  and 
strength  especially  developed  in  the  lower  extremities,  and  by  increased 
reflexes  and  spasticity.  The  special  paraplegic  features  which  they 
possess  will  be  taken  up  in  the  description  of  the  various  system  dis- 
eases. In  this  present  connection  the  paraplegic  state  arising  from 
indiscriminate  lesions  is  principally  in  view. 

If  the  initial  cord  lesions  be  acute,  as  in  traumatism,  hemorrhage,  and 
myelitis,  the  motor  loss  is  promptly  established  and  the  muscles  are 
flaccid  and  inert.  The  sphincters  are  usually  relaxed.  The  reflexes 
represented  in  the  diseased  cord  segments  are  abolished  and  those  below 
the  injured  focus  are  diminished.  If  the  cord  is  entirely  severed,  they 
are  completely  and  permanently  lost  and  rigidity  does  not  ensue.    When 


360 


DISEASES   OF  THE  CTjRD  PROPER. 


the  cord  is  not  entirely  divided,  at  the  end  of  a  week  in  some  cases,  in 
others  several  weeks  later,  the  increasing  reflexes  indicate  degenerating 
lateral  motor  tracts  and  usher  in  the  spastic  features  that  are  to 
permanently  remain. 

When  the  inciting  cause  of  the  paraplegia  is  of  gradual  develop- 
ment, as  in  pressure  conditions  arising  from  Pott's  disease  and  spinal 
neoplasms  or  new  growths  in  the  membranes  or  cord,  the  clinical  pro- 
gram is  very  diiferent.  Root  pains,  girdling  the  trunk  or  streaking  into 
the  limbs,  depending  on  the  segment  location  of  the  lesion,  are  early 
symptoms  and  usually  there  is  complaint  of  heaviness,  weakness,  and 
clumsiness  in  the  legs.  This  increases  either  steadily  or  by  stages,  in 
the  intervals  of  which  some  amelioration  may  occur,  and  eventually  the 
hypersensitive  girdle  and  subjacent  anesthesia  are  more  or  less  well  de- 
veloped. Sphincteric  loss  is  a  late  feature  and  is  usually  preceded  by 
months  of  slighter  degrees  of  incontinence.  As  the  pressure  increases^ 
compression  of  the  pyramidal  tracts  gradually  develops  ;  they  degener- 
ate and  the  reflex  activity  is  correspondingly  exalted.  It  is  in  these 
cases  of  slow  cord  compression  that  the  spasticity,  reflex  automatism. 


Fig.  132. — Paraplegic  gait. 


Figs.  133  and  134. — Station  in  spastic  paraplegia  due 
to  syphilitic  luyelilis,  showing  rigidities,  flexed  knees, 
and  adducted  thighs. 


and  muscular  rigidity  with  resultant   contractures   reach  their  highest 
exemplification. 

AVhen  the  acute  cases  have  improved  enough  to  walk  or  the  insidi- 
ous cases  have  attained  a  fair  degree  of  development,  the  gait  is  highly 
characteristic.     The  patient's  feet  once  planted  seem  glued  to  the  floor. 


INDISCRIMINATE   CORD   LESIONS.  361 

aiifl  the  upper  portion  of  the  body  is  inclined  forward  in  advancing. 
The  pelvis  is  elevated  on  one  side  and  that  limb  is  then  brought  or 
dragged  to  a  position  under  the  center  of  gravity  like  a  rigid  pendulum 
(Fig.  132).  It  may  even  be  aided  by  the  hand.  As  it  advances  it  is 
shaken  by  clonic  movements,  and  when  planted  these  may  cause  it  to 
execute  several  dancing  steps  before  it  is  securely  placed,  during 
which  the  heel  is  forcibly  elevated  and  the  patient  may  be  bodily 
jostled  up  and  down.  The  body  is  then  again  inclined  forward  over 
the  supporting  liml),  and  the  opposite  member  is  in  turn  carried  a 
little  in  advance  of  its  fellow.  These  short,  jerky,  halting,  cloni- 
cally  disturbed  steps  are  frequently  rendered  more  difficult  by  the  over- 
action  of  the  adductors  of  the  thighs  which  displace  the  limbs  inward, 
cause  the  knees  to  interfere  with  each  other,  and  sometimes  even  induces 
a  cross-legged  gait.  Progress,  jn  spite  of  the  disturbance  of  the  gait,  is 
usuallv  made  in  a  fairly  straight  line,  unless  some  slight  obstacle  over 
which  the  patient  is  sure  to  stumble,  or  an  unusual  amount  of  clonus, 
cause  him  to  swerve.  In  nearly  every  respect  the  gait  is  the  opposite 
of  the  steppage  of  multiple  neuritis. 

If  walking  is  impossible,  the  attitude  in  standing  may  still  indicate 


]Fig.  135. — Paraplegia  from  spinal  fracture.     Attitude  in  bed.     Thighs  adducted  and  crossed.     Bedsore 

over  trochanter. 

the  spastic  state.  The  tendency  to  contracture  usually  draws  the  knees 
forcibly  together  and  partially  flexes  the  knee-  and  hip-joints  (Figs.  133 
and  134).  A  sudden  reflex  contraction  of  the  calf-muscles  may  cause 
the  patient  to  rise  on  his  toes  or  throw  him  to  the  ground.  The  knees 
often  suddenly  give  way. 

When  the  patient  is  bedridden  and  the  paraplegic  state  is  developed 
to  an  extreme  degree,  the  lower  limbs  may  be  rigidly  extended  on  the 
pelvis  and  at  all  their  joints.  Adduction  is  strongly  marked  and  may 
even  cross  the  limbs.  If  one  foot  be  lifted  from  the  bed,  the  rigidity 
may  serve  to  cause  the  other  one  to  follow,  as  if  the  hip-  and  knee-joints 
were  ankylosed.  In  other  severe  cases  flexion  predominates,  and  the 
lower  extremities  are  rigidly  folded  upon  themselves  and  upon  the  trunk, 
so  that  the  heels  are  drawn  up  to  the  buttocks,  the  knees  to  the  sternum. 

The  reflexes  are  always  exaggerated  after  the  early  flaccidity  of 
acute  cases  has  receded,  and  in  the  later  stages  become  excessive  to  an 
incredible  degree.  The  slightest  tap  on  the  patellar  tendon  forcibly 
throws  out  the  leg,  and  the  whole  extremity  may  be  seized  with  a  clonic 
activity  that  provokes  jerky,  more  or  less  rhythmical,  movements  which 
may  also  appear  in  the  opposite  limb,  and  finally  end  by  a  jack-knife 
contraction  that  violently  flexes  both  extremities  upon  the  trunk  and  at 


362  DISEASES  OF  THE  COED  PROPER. 

the  knees.  These  reflex  storms  may  even  follow  the  slightest  cutaneous 
impression,  such  as  gently  removing  the  bed-clothing,  and  are  not  infre- 
quently the  source  of  much  pain  and  suffering.  The  vesical  and  rectal 
reflexes  usually  work  automatically  in  protracted  cases  of  paraplegia, 
and  are  only  slightly  under  the  patient's  control,  or  entirely  beyond  it. 
Lesions  in  the  lumbar  cord  may  destroy  them.  When  the  upper  dorsal 
or  lower  cervical  cord  is  aifected,  priapism  is  frequently  present,  and 
cervical  lesions  cause  dilatation  of  the  pupils. 

All  of  these  conditions  vary  from  the  slightest  to  the  most  extensive 
degree  in  different  cases.  Slow  compression  of  the  cord,  as  by  tumor, 
gives  the  most  highly  colored  picture,  ataxic  paraplegia  perhaps  the  least. 

The  amount  and  character  of  the  sensory  disturbance  naturally  de- 
pend on  the  extent  of  damage  to  the  posterior  half  of  the  cord. 
Atrophy  of  muscles  is  in  the  same  way  dependent  upon  the  destruction 
of  the  anterior  gray  and  is  related  to  the  vertical  extent  of  that  destruc- 
tion. More  or  less  general  emaciation,  due  to  inactivity  and  depressed 
systemic  conditions,  is  commonly  present.  Contractures  produce  de- 
formities that  still  further  cripple  the  patient. 

The  prognosis  naturally  depends  on  the  character  of  the  cord 
lesion.  The  removal  of  pressure  in  Pott's  disease  and  in  spinal  tumors  by 
operation,  frequently  results  satisfactorily  and  the  cord  functions  return 
to  a  normal  state.  When  the  spasticity  is  the  result  of  destructive  le- 
sions of  the  cord,  as  in  myelitis  and  traumatism,  some  disability  is  bound 
to  persist.  It  may  eventually  be  very  slight  or  it  may  progressively 
increase.     Every  case  must  be  individually  considered. 

Treatment. — The  treatment  of  the  paraplegic  state  consists  of:  (1) 
Removing  the  cause  if  possible  ;  (2)  preventhig  contracture  distortions 
or  correcting  them  by  surgical  means,  such  as  tenotomies  and  orthope- 
dic apparatus ;  (3)  the  use  of  electricity  and  massage  to  atrophied 
muscles  ;  (4)  general  measures  to  build  up  the  systemic  condition  ;  (5) 
local  applications  over  the  spine  to  control  any  lingering  inflamma- 
tory state  or  to  hasten  absorption  of  exudate,  and  (6)  of  the  administra- 
tion of  spinal  sedatives  to  reduce  the  reflex  excess.  Looal  conditions, 
such  as  indolent  ulcers,  cystitis,  and  incontinence,  furnish  their  own 
indications.  It  will  often  be  found  that  massage  and  electricity  pro- 
duce so  much  reflex  stimulation  that  they  must  be  discontinued.  Hot 
baths  often  produce  a  grateful  relaxation.  Counterirritation  to  the  spine 
and  the  resources  of  hydrotherapy  sometimes  are  of  great  advantage. 

LANDRY'S  PARALYSIS  (ACUTE  ASCENDING  PARALYSIS). 
The  case  observed  by  Landry, ^  reported  in  1859,  presented  these 
striking  peculiarities :  An  acute  paralysis  beginning  in  the  legs,  extending 
to  the  trunk  and  arms,  soon  involving  the  bulbar  centers,  and  terminating 
fatally.  The  paralysis  was  not  marked  by  loss  of  sensation  ;  the  sphinc- 
ters were  not  involved.  The  muscles  retained  their  faradic  irritability, 
the  mind  was  not  disturbed,  and  the  temperature  was  practically  normal. 
No  changes  were  found  in  the  central  nervous  apparatus  by  microscopical 
examination,  but  the  spleen  was  acutely  enlarged. 

1  "  Gazette  Heb.,"  1859. 


INDISCRIMINATE   CORD  LESIONS.  363 

Since  that  time  several  hundred  cases  have  been  reported  as  instances 
of  Landry's  paralysis,  some  of  which  correspond  closely  while  others 
depart  materially  from  the  original  outline.  Of  these  latter  we  may 
say  that  most  of  them  were  cases  of  multiple  neuritis,  some  were  cases 
of  poliomyelitis  anterior,  and  others  were  cases  of  cross  or  disseminate 
myelitis  with  extension.  With  improved  methods  of  investigation 
there  has  gradually  accumulated  a  considerable  number  of  cases  which 
are  clinically  true  to  the  prototype,  but  show  organic  disease  in  the 
spinal,  bulbar,  and  even  in  the  cerebral  matter  and  in  the  nerve- 
roots  and  peripheral  nerves.  With  the  development  of  bacteriology 
we  may  now  add  typical  cases  in  which  infectious  bacteria  have 
been  observed  in  the  spinal  cord  or  obtained  by  cultures  from  it.  We 
are,  therefore,  justified  in  defining  Landry's  paralysis  as  an  acute  infec- 
tious ascending  paralysis  due  to  an  infectious  or  toxic  condition  that  may 
induce  a  myelitis  largely  confined  to  the  anterior  gray  matter  of  the 
cord  and  which  may,  in  addition,  cause  root  involvement,  peripheral 
neuritis,  and  changes  in  the  medulla  and  cortex  of  a  similar  nature  to 
those  in  the  cord. 

Etiology. — This  form  of  spinal  palsy  is  about  four  times  as  fre- 
quent in  adults  as  in  children,  according  to  the  tabulation  of  selected 
cases  by  Bailey  and  Ewing,i  and  affects  males  nearly  three  times 
as  often  as  females.  It  has  followed  close  upon  or  occurred  during 
attacks  of  numerous  infectious  diseases  and  conditions.  Small-pox, 
tuberculosis,  typhoid,  pneumonia,  diphtheria,  syphilis,  influenza,  pelvic 
cellulitis,  the  puerperium  and  obscure  febrile  disturbances  have  seemed 
to  play  a  part  in  its  inception.  Alcoholism  2  and  exposure  to  cold  are 
also  rather  frequently  mentioned,  but  in  numerous  cases  not  the  slightest 
cause  has  been  detected  and  the  patient  apparently  was  in  good  health 
previous  to  the  paralysis.  The  toxic  features  of  many  of  the  alleged 
causes  jump  with  the  clinical  manifestations  which  are  highly  significant 
of  an  infectious  state,  and  coincide  with  the  few  bacteriological  findings 
that  have  been  reported.  The  idea  of  a  toxemia  which  has  an  elective 
action  for  the  spinal  gray  producing  first  dynamic  conditions,  later  fol- 
lowed by  histological  changes,  best  explains  the  various  postmortem 
findings  and  the  clinical  manifestations  of  the  disease.  That  the  infection 
reaches  the  cord  through  the  blood  is  abundantly  shown  by  the  perivas- 
cular changes  and  the  frequent  limitations  of  the  myelitic  invasion  to 
the  territory  irrigated  by  the  anterior  median  arteries  and  the  vessels 
reaching  the  anterior  horns  along  the  motor  roots. 

Morbid  Anatomy. — In  the  older  reports,  as  in  the  first  instance, 
no  morbid  changes  were  detected  anywhere  in  the  nervous  system.  As 
methods  improved  and  data  multiplied,  reports  of  myelitic  softening, 
especially  in  the  gray  matter,  but  also  implicating  the  neighboring  white 
fibers  of  the  dorsal  and  cervical  cord,  degeneration  in  root-fibers  and  peri- 
pheral nerves,  and,  finally,  changes  in  the  medulla,  cerebrum,  and  cere- 
bellum were  made.  A  majority  of  cases,  whether  showing  cord  changes  or 
not,  presented  an  acutely  enlarged  and  softened  spleen  and  often  engorged 

1  "  N.  Y.  Med.  Jour.,"  July,  1896. 

2  Krewer,  "Zeitschr.  f.  klin.  Med.,"  Bd.  xxxii. 


364  DISEASES   OF  THE   COED  PROPER. 

Ivmphatie  glands.  Of  late  no  case  that  has  been  systematically  and  com- 
petently examined  has  given  negative  findings.  The  cellular  structures 
of  the  anterior  gray  or  the  cylinder  processes  arising  in  the  motor  cornual 
cells  are  foimd  disturbed.  Eisenlohr,  Ross,  Hoffman,  Immerman,  Cursch- 
mann,  Ketli,  Hlava,  Marinesco,  Bailey  and  Ewing  all  found  such 
changes  varying  from  fragmentation  of  the  cylinder  process  or  slight 
swelling  of  the  cell  bodies  and  chromophilic  changes  of  the  cell  proto- 
plasm to  well-defined  poliomyelitis  and  diffuse  cellular  infiltration 
throughout  the  spinal  gray.  Frequently  the  blood-vessels  show  a  peri- 
vascular small-cell  infiltration  and  the  motor  cells  present  marked  de- 
generative changes.  In  cases  of  sufficient  intensity  and  duration  the 
peripheral  nerves  are  degenerated  and  muscular  degeneration  and  even 
atrophy  are  added.  The  cranial  nerve  nuclei  and  the  cellular  and  vas- 
cular elements  of  the  cerebral  and  cerebellar  cortex  were  similarly 
affected  in  Ewing's  case.^ 

Bacteriological  examinations  have  sometimes  been  made  with  nega- 
tive results  and  suitable  stains  have  often  failed  to  show  bacteria  in  the 
cord  sections.  Remlinger  -  met  with  this  experience  even  when  cultures 
from  the  cord  readily  developed  streptococcus  pyogenes  and  streptococci 
were  also  found  in  the  lymph-spaces  of  the  gray  matter  of  certain  other 
portions  of  the  cord.  Eisenlohr  found  the  staphylococcus  pyogenes 
aureus  in  all  cultures  and  staphylococcus  aureus  in  cultures  from  the 
spleen.  Centanni  found  a  rounded  bacillus  in  the  peripheral  nerves. 
Giuzetti  found  chromogenic  bacilli  in  cord  cultures.  Marinesco  found 
cocci  in  the  ganglion-cells.  Roger  and  Josne  ^  have  demonstrated  the 
pneumococcus.  Thoinot  and  Masseline  have  produced  spinal  paralysis 
in  rabbits  by  the  intravenous  injection  of  staphylococcus  pyogenes  aureus 
and  of  bacillus  coli. 

Symptoms. — Acute  ascending  paralysis  may  develop  during  an 
attack  of  some  infectious  disease  or  may  follow  it.  In  several  epi- 
demics of  poliomyelitis  such  cases  have  been  encountered.  Fre- 
quently, however,  it  comes  on  without  malaise,  fever,  or  premonitorv 
symptoms,  usually  without  tingling,  numbness,  or  other  sensorv  disturb- 
ance. A  feeling  of  weakness  begins  in  the  feet  and  legs,  and  slowly  creeps 
ujjward,  becoming  more  and  more  pronounced  in  the  lower  levels  as  the 
disease  mounts.  It  may  affect  one  leg  first  or  most.  At  the  end  of 
two  or  three  days  or  a  week  the  lower  extremities  are  completely  para- 
lyzed and  the  weakness  has  involved  the  trunk  and  upper  limbs.  The 
breathing  becomes  superficial  from  involvement  of  the  thorax,  and 
difficulty  in  swallowing  soon  appears.  In  severe  cases  everv  voluntary 
muscle  below  the  face  is  completely  paralyzed  and  relaxed,  and  even 
the  cranial  nerves  may  be  involved,  especially  the  ocidomotor,  facial, 
and  hypoglossal.  Cerebral  and  mental  symptoms  are  absent  until  the 
dyspnea  or  cardiac  failure  is  pronounced  and  induces  them.  The 
sphincters  are  not,  as  a  rule,  relaxed ;  there  is  no  tendency  to  bedsores 

1  Loc.  cit.  -  '•Comptes  Eendus  de  la  Soc.  de  Biol.,"  April,  If^dS. 

3  "Presse  med.."  July  27,  1898. 


INDISCRIMINATE  CORD  LESIONS.  365 

or  dystrophy  ;  the  tendon  and  superficial  reflexes  are  usually  present ;  the 
electrical  responses  arc  normal ;  and  sensation,  together  with  the  special 
senses,  is  not  perverted.  If  a  fatal  issue  do  not  occur,  the  symptoms 
of  paralysis  slowly  recede  in  tlie  reverse  order  of  their  appearance,  and 
when  they  have  distinctly  subsided  from  the  upper  levels  recovery  may 
be  anticipated. 

In  some  cases  the  onset  is  reversed,  the  upper  extremities  first 
showing  weakness ;  and,  indeed,  the  ordinary  type  may  be  greatly 
modified,  as  can  be  readily  understood  from  the  varying  anatomical 
distribution  of  the  organic  lesions  in  well-authenticated  observations. 
In  one  case  falling  under  the  writer's  attention,  where  the  clinical 
history  was  typical,  complete  wasting  of  isolated  muscle-groups  in  all 
four  extremities  occurred,  and  persisted  four  years  later,  without  any 
appearance  of  ultimate  improvement.  Paresthesia  and  dysesthesia  are 
not  rare,  and  anesthesia  may  gradually  follow  the  paralytic  invasion, 
advancing  in  a  similar  manner.  The  reflexes  may  also  subside  and  dis- 
appear in  an  ascending  progression.  Even  electrical  modifications  and 
the  reaction  of  degeneration  are  encountered.  The  progress  of  the 
paralysis  may  stop  at  any  point,  and  then  recede.  A  temperature  of 
101°  to  103°  F.  has  been  observed,  but,  as  a  rule,  it  does  not  rise 
above  the  normal.  Profuse  perspiration  sometimes  and  splenic  enlarge- 
jncnt  frequently  are  encountered  and  bespeak  the  toxic  state. 

Course. — The  course  from  inception  to  fatal  termination  may  be 
very  brief, — less  than  two  days, — and  fatal  cases  usually  end  within  ten 
days.  Prolonged  cases  may  only  reach  their  acme  in  a  month.  After 
a  stationary  period  of  varying  length  in  the  hopeful  cases,  improvement 
takes  place  usually  in  a  retreating  order,  but  convalescence  is  slow  and 
may  require  months.  On  the  other  hand,  it  may  be  rapid,  or,  as  in  the 
case  previously  mentioned,  permanent  injury  may  result. 

Diagnosis. — The  diagnosis  in  some  cases  must  necessarily  be 
extremely  difficult,  but  in  the  typical  form  is  readily  made,  providing 
the  existence  of  this  rare  disease  is  kept  in  mind.  It  rests  upon  the 
method  of  invasion,  the  pure  motor  paralysis,  the  comparatively  negative 
conditions  as  to  reflexes,  sensation,  and  electrical  reactions,  and  the  his- 
tory of  some  possible  toxemic  state.  Somes  cases  are  complicated  by 
hysteria,  which  is  capable  of  greatly  obscuring  the  diagnosis.  When 
slight  electrical  changes  and  paresthesise  are  present,  it  is  impossible  to 
exclude  neuritis,  and  the  occurrence  of  peripheral  nerve-lesions  in  some 
instances  has  already  been  pointed  out.  In  meningitis  the  pain  and 
rigidity  are  distinctive.  In  cross-myelitis  we  have  all  spinal  cord  func- 
tions involved  below  a  definite  level  and  lack  the  ascending  features. 

Prognosis  is  always  grave,  since  even  in  the  irregular  and  prolonged 
cases  one  can  not  foretell  at  what  moment  bulbar  symptoms  may  appear, 
and  the  main  danger  to  life  depends  on  their  presence.  Rapidly 
ascending  symptoms  imply  a  speedy  termination,  but  there  is  no 
invariable  rule.  Only  wlien  the  tide  has  turned  and  symptoms  are 
receding  can  one  entertain  a  reasonably  hopeful  prognosis.  The  pres- 
ence of  neuritic  conditions  or  of  electrical  changes  implies  a  prolonged 
convalescence  and  doubt  as  to  ultimate  complete  recovery.  Where 
cerebral  symptoms  appear  they  are  of  bad   import,    signifying  either 


366  DISEASES  OF  THE  COED  PROPER. 

profound  toxic  conditions  or  the  near  approach  of  death  from  cardiac 
or  respiratory  failure. 

Treatment  will  be  directed  against  any  general  toxic  condition  pres- 
ent or  reasonably  suspected.  The  salicylates,  tincture  of  the  chlorid  of 
iron  in  full  doses,  bichlorid  of  mercury  to  the  point  of  toleration,  thor- 
ough cleansing  and  disinfection  of  the  alimentary  tract,  supportive  diet, 
conservation  of  nervous  energy  and  strength,  are  valuable.  To  the 
spine  a  narrow  sinapism  the  whole  length  of  the  back,  frequently  re- 
peated, is  of  service  ;  even  the  thermocautery  is  advised  by  some.  The 
paralyzed  limbs  should  be  gently  massaged  to  improve  circulation  and 
give  comfort.  When  swallowing  becomes  difficult  or  impossible,  feed- 
ing by  the  stomach,  nasal,  or  rectal  tube  must  be  adopted,  and  the  prefer- 
ence is  for  the  nasal  tube,  providing  care  be  exercised  to  avoid  passing  it 
into  the  larynx.  During  convalescence,  massage,  electricity,  local  douches, 
tonics,  generous  diet,  and  general  measures  are  the  main  reliance. 

CAISSON  DISEASE,  OR  DIVERS'  PALSY. 

Workmen  and  others  subjected  to  high  atmospheric  pressure,  as  in  de- 
scending to  great  depths  in  diving  apparatus,  or  in  making  certain  exca- 
vations by  caisson  construction,  are  frequently  affected  with  cerebral 
symptoms  and  paralytic  conditions  of  mainly  a  paraplegic  character. 
The  disturbance  varies  in  intensity  from  slight  giddiness  and  neuralgic 
pains  to  paraplegia.  Even  sudden  death  may  occur.  The  symptoms 
appear  while  the  air-pressure  is  being  reduced,  or  within  the  following 
half-hour.  In  a  minor  degree,  high  altitudes,  as  mountain  climbing  and 
ballooning,  furnish  analogous  conditions  and  symptoms. 

Etiology. — The  cause  of  divers'  palsy  is  not  so  much  the  increased 
atmospheric  pressure,  as  its  sudden  reduction.  A  number  of  predispos- 
ing causes  have  also  been  fairly  determined.  Advanced  age,  alcoholism, 
heart  and  kidney  disease,  obesity,  hunger,  and  any  condition  of  physical 
depression  furnish  a  liability  to  its  onset.  On  the  other  hand,  those 
who  have  for  months  been  gradually  subjected  to  increasing  air-pressure 
acquire  in  some  degree  an  immunity  by  habituation.  The  length  of  ex- 
posure and  the  amount  of  pressure  are  followed  by  proportionate  effects, 
but  symptoms  rarely  result  unless  the  pressure  reach  two  atmospheres — 
thirty  pounds. 

The  mechanism  producing  the  palsy  or  the  slighter  symptoms  is  fur- 
nished by  the  vascular  apparatus.  Various  theories  have  been  advanced 
to  explain  the  results.  One  supposes  that  during  the  time  of  increased 
air-pressure  the  superficial  and  peripheral  parts  of  the  body  are  exsan- 
guinated and  the  central  organs  actively  congested  to  a  similar  degree. 
This  congestion  reaches  such  a  point  that  the  capillary  field  becomes 
paretic  from  distention,  and  can  not  promptly  deliver  itself  of  its  super- 
abundant blood  when  pressure  is  removed  from  the  periphery.  A  pass- 
ive congestion  then  ensued,  with  a  stagnant  blood-current.  The  lower 
cord  is  placed  at  an  especial  disadvantage  through  its  arterial  arrange- 
ment, which  mechanically  conduces  to  maintain  the  vascular  stagnation. 
Serous  effusion  into  the  cord  and  meninges  may  thus  follow,  or  the 
effusion  may  be  hemorrhagic.^ 

^  Hirt,  ' '  Handbuch  der  spec.  Pathologie  und  Therapie, ' '  vol.  i. 


INDISCRIMINATE  CORD  LESIONS.  367 

Another  and  apparently  more  important  feature  is  added  to  the 
congestive  state.  The  oxygen,  nitrogen,  and  carbon  dioxid  of  the 
blood,  increased  under  the  high  pressure,  are  liberated  by  restored 
low  pressure,  and,  expanding,  fill  the  passively  congested  vessels 
with  gaseous  bubbles,  producing  something  like  an  air  embolism. 
The  gases  also  escape  into  the  tissues.  Catsaras,  of  Athens,  has 
seen  gas  bubbles  in  the  vessels  and  even  in  the  cord  parenchyma 
of  dogs  subjected  to  high  air-pressures,  and  gas  has  been  seen  in 
the  tissues  and  vessels  in  some  human  autopsies  after  death  from  this 
cause.  If  vascular  accidents  do  not  follow,  the  circulation  is  gradually 
equalized,  the  oxygen  is  absorbed  or  removed  by  respiration,  and  symp- 
toms subside.  P.  Bert,  Hoche,^  and  Snell  ^  have  practically  proven 
the  gas  theory.  Edemata,  effusions,  and  hemorrhages,  naturally,  produce 
more  or  less  lasting  symptoms  in  the  brain  and  especially  in  the  cord. 

Morbid  Anatomy. — In  the  few  autopsies  on  record,  which  have 
all  been  made  some  days  or  weeks  after  the  onset  of  the  attack,  the 
cord  has  always  been  found  abnormally  congested.  Small  hemorrhages 
have  been  seen  and  diffuse  myelitis  with  degenerative  tracts  have  been 
noted.  In  some  cases  there  has  been  an  edematous  condition  of  the 
membranes  and  cord.  Hemorrhages  into  parenchymatous  organs  and 
mucous  surfaces  have  also  been  observed.  The  secondary  myelitis  is 
most  pronounced  in  the  dorsal  half  of  the  lumbar  cord  and  the  anterior 
horns  are  practically  unaffected.  In  other  words,  that  portion  of  the 
cord  which  has  the  best  vascular  supply,  and  where  stasis  and  edema 
would  first  subside,  ordinarily  escape  injury.  The  painful  manifesta- 
tions of  the  attack  are  perhaps  explained  by  the  location  of  the  vascular 
disturbance  in  the  sensory  portion  of  the  cord. 

Symptoms  arise  as  the  air-pressure  is  being  reduced,  or  shortly 
thereafter,  and  may  appear  while  the  men  are  in  the  locks  or  chambers 
that  are  placed  between  the  various  pressures  or  after  the  patient  has 
gone  some  distance  in  the  open  air.  At  first  the  cerebral  features  pre- 
dominate; headache,  giddiness,  faintness,  nausea,  vomiting,  delirium, 
double  vision,  and  even  coma  may  precede  or  accompany  the  spinal 
symptoms.  These  consist  of  paroxysmal  pains,  frequently  of  great 
intensity.  They  usually  are  felt  in  the  legs,  but  may  affect  the  trmik  or 
upper  limbs.  Their  relation  to  the  posterior  portion  of  the  cord  has 
already  been  mentioned.  Soon  the  patient  feels  numbness  and  weak- 
ness in  his  legs,  which  may  increase  rapidly  to  complete  paraplegia, 
usually  confined  to  the  lower  extremities,  but  it  may  extend  downward 
from  any  spinal  level.  It  involves  motion,  sensation,  and  the  sphinc- 
ters, and  presents  clinically  the  features  of  a  cross-lesion  of  the  cord  of 
rapid  onset.  In  extreme  cases  the  patient  falls  dead,  or,  after  stagger- 
ing a  little,  falls  and  expires  with  or  without  delirium  and  convulsions. 
Symptoms  may  be  most  variously  combined  and  show  any  grade  of  inten- 
sity. The  majority  recover  promptly.  Of  those  coming  under  treat- 
ment about  one-half  recover,  about  half  have  lasting  paralysis,  and 
about  three  per  cent.  die.     Those  who  do  not  recover  within  the  first 

1  "Berlin,  klin.  Wocheiis.,"  May  31,  1897. 
^  ' '  Compressed-air  Illness, ' '  London,  1896. 


368  DISEASES  OF  THE  COED  PROPER. 

three  or  four  days  present  the  symptoms  and  run  the  course  of  a  lumbar 
or  dorsal  myelitis  of  varying  extent  and  severity. 

Treatment. — Prophylaxis. — Persons  who  are  to  be  subjected  to 
increased  air-pressure  should  be  rigidly  examined.  Those  presenting 
the  predisposing  conditions  mentioned  should  be  excluded.  Only  hardy 
young  men  with  sound  hearts  and  regular  habits  should  be  accepted  for 
this  work,  and  spare  individuals  are  preferable.  In  case  of  an  extensive 
undertaking  the  same  men  should  be  employed  throughout  the  task,  that 
they  may  be  habituated  to  the  increasing  pressure  as  the  work  progresses, 
thereby  gaining  immunity.  In  a  pressure  of  over  thirty  pounds  they 
should  work  short  shifts  of  two  hours  or  less,  and  plenty  of  time  should 
be  taken  in  passing  the  locks.  Smith ^  says  five  minutes  for  each  fifteen 
pounds  of  extra  pressure.  Inexperienced  persons  should  take  much 
more.  It  is  well  not  to  enter  the  pressure  fasting.  Snell  lays  stress 
on  ventilating  the  works  to  reduce  the  amount  of  gases  in  the  circula- 
tion as  well  as  on  general  principles. 

Treatment  of  the  Attack. — If  symptoms  arise,  the  patient  should  be 
hurried  back  into  the  caisson,  and  if  the  symptoms  subside,  as  they 
often  do,  very  slowly  returned  to  the  outer  air.  Morphin  is  often 
required  for  the  intense  pain.  Ergot  in  dram  doses  of  the  fluid 
extract  every  hour  will  sometimes  relieve  the  pain  and  apparently 
check  the  disease.  It  has  been  suggested  to  bandage  the  limbs,  and 
even  the  trunk,  thereby  restoring  something  of  the  surface  pressure 
and  maintaining  the  spinal  circulation.  When  paralytic  features  have 
developed,  the  treatment  is  that  of  myelitis. 

TUMORS  OF  THE  SPINAL  CORD  AND  ITS  VARIOUS  ENVELOPES. 
New  growths  arising  in  the  spinal  meninges  or  on  the  inner  surface  of 
the  bony  canal  or  in  the  cord  itself  produce  definite  symptoms  only  as  the 
cord  or  the  nerve-roots  are  disturbed.  They  may  be  properly  grouped 
together  because  of  their  common  symptomatology,  which  renders  a 
positive  clinical  diagnosis  as  to  their  original  sites  impossible,  and  makes 
every  operation  for  their  removal  in  a  limited  sense  an  exploratory  one. 
The  importance  of  an  early  diagnosis  of  these  tumors  is  emphasized  by 
the  fact  that  most  of  them  can  be  successfully  removed  if  taken  in  time, 
and  the  fatality,  which  otherwise  attends  them,  averted.  The  paraplegia 
to  which  they  give  rise  may  in  the  same  way  be  prevented,  and  in  some 
instances  caused  to  recede  when  not  too  far  advanced. 

There  are  now  in  the  literature  less  than  200  reported  cases,  so  that 
tumors  involving  the  cord  are  rare.  Those  arising  from  the  meninges 
and  extradural  structures  are  about  six  times  as  numerous  as  those  pri- 
marily cordal.  Sarcoma  and  its  varieties  furnish  more  than  one-third 
of  the  tumors,  tubercle  and  echinococcus  each  about  a  tenth,  and  carci- 
noma and  all  varieties  of  benign  growths,  including  gumma,  the  balance. 
Glioma,  which  is  so  common  in  the  brain,  also  appears  in  the  cord.  It 
is  usually,  however,  distributed  closely  about  the  central  canal  or  in 
longitudinal  bands  in  the  substance  of  the  cord,  where,  undergoing  de- 
generation, it  produces  channels  or  false  canals.  These  give  rise  to 
^  Pepper's  "System  of  Medicine,"  vol.  iii. 


INDISCRIMINATE   CORD  LESIONS. 


369 


definite  symptoms  and  a  clinical  type,  which  is  called  syringomyelia. 
It  is  described  in  a  later  chapter. 

Tumors  aifecting  the  spinal  cord  are  usually  of  small  dimensions 
owing  to  the  rapidity  with  which  they  destroy  the  cord  and  lead  to  a 
fatal  issue.  They  are  commonly  single,  but  several  tubercular  growths 
and  multiple  sarcomata  and  neuromata  have  been  reported.  The 
favorite  location  of  spinal  growths  is  in  the  dorsal  and  lower  cervical 
regions.  Regarding  the  causation  of  spinal  tumors,  the  same  ideas 
exist  as  pertain  to  the  development  of  tumors 
-elsewhere.  Traumatism  is  often  alleged  and 
may  undoubtedly  serve  to  locate  a  syphilitic 
process  and  perhaps  to  favor  the  invasion  ot 
tubercle  and  angiomatous  growths.  Its  rela- 
tion to  malignant  neoplasms  is  largely  supposi- 
titious. 

Morbid    Anatomy. — The    post-mortem    ex- 
amination reveals  the  new  growths  arising  from  ^Vr^J^. 
the    extradural    tissues,   the    membranes,    or   the 
cord,  in  the  substance  of  which  it  may  rarely  be 
embedded. 

several  nerve- 
It  may  have 
From  press- 
zone  of  softened 
show: 


an    in- 


m 


It  frequently  is  traversed   by 
roots,  or  these  may  be  destroyed, 
a  vertical  extent  of  several  inches, 
ure   upon  the   cord  there   is  a  z( 
cord-substance    which    frequently 
flammatory  condition.     The  cord   may  be  much 
indented    by  the   growth,  or  compressed   almost 
to  complete  division.     Changes  in  the  cord  sub- 
stance   due   to    pressure-atrophy,   softening,    and 
myelitis  are  present  with  resulting  secondary  de- 
generations related  to  the  portion  of  the  cord  that 
is  affected.     The  consequences  of  myelic  soften- 
ing and  myelitis  are  found  in  the  muscles,  bladder, 
kidneys,  etc.,  depending  in  distribution  upon  the 
anatomical  and  clinical  features  of  the  given  case. 
The  various  growths  are  marked  by  their  ordinarj^ 
individual  characteristics  and  histological  peculi- 
arities. 

Symptoms. — The  initial  and  most  common 
symptom  of  spinal  tumor  is  usually  pain.  This 
is  of  two  varieties  :  first,  that  referable  to  irrita- 
tion of  the  posterior  roots,  and,  second,  that  due  to  disturbance  of 
the  sensory  tracts  in  the  cord.  The  first  gives  rise  to  girdling  sensa- 
tions and  partially  follows  in  distribution  the  fields  of  the  peripheral 
nerves.  The  second  follows  the  segmental  outlines  and  may  also  give 
rise  to  pains  referred  to  parts  below  the  lesion  whose  sensory  pathways  in 
the  cord  are  irritated.  If  these  pathways  are  broken,  the  pain  may  be 
referred  to  an  area  actually  anesthetic.  The  root  pains  and  the  segmental 
<or  cord  pains  are  frequently  combined.  Ordinarily  the  pain  is  bilateral. 
24 


t 


Fig. 


136.— 1  iiiu'jr  of  the  cord 
(Leydeu;. 


370  DISEASES  OF  THE   CORD  PROPER. 

It  may  occur  first  on  one  side,  but,  arising  as  it  usually  does  from  pres- 
sure upon  the  cord,  it  is  evident  from  the  anatomical  situation  that  pres- 
sure and  counterpressure  must  be  equal  and  the  ^vhole  diameter  of  the 
cord  soon  affected.  When  the  tumor  is  within  the  cord  and  laterally 
situated,  a  partial  Brown-Sequard  palsy  may  develop  at  first,  but  ordi- 
narily soon  yields  to  the  cross  variety  and  the  paraplegic  syndrome. 
The  pains  are  of  all  degrees  of  severity,  but  frequently  atrocious  in 
their  intensity,  of  a  lightning,  darting,  ripping  character,  with  parox- 
ysms and  remissions. 

The  nerve-trunks  are  so  rarely  sensitive  that  Starr,  ^  in  a  masterlv 
resume  of  the  subject,  states  that  he  never  noted  it  in  his  own  experience 
or  in  the  literature.  Pain  over  the  seat  of  the  tumor  is  also  rare,  and, 
when  present,  following  the  usual  rule,  is  felt  one  or  two  inches  below 
the  level  of  the  lesion. 

The  reflexes  comport  themselves  as  in  the  paraplegic  state  gener- 
ally (see  p.  359).  Those  which  find  their  nuclear  representation  in 
the  diseased  segments  are  lost  early.  Those  below  the  lesion  are  exag- 
gerated as  the  compression  is  brought  to  bear,  and,  in  extreme  cases 
reach  the  highest  degree  of  intensification.  Should  the  cross-lesion  of 
the  cord  become  absolute,  constituting  a  cord-division,  all  reflexes  are 
lost  below  the  affected  level.  The  rectal  and  vesical  reflexes  are  sub- 
ject to  the  ordinary  rules  of  the  paraplegic  state.  Motor  disturbances  of 
a  paraplegic  sort  rarely  precede  the  sensory  disturbance,  but  usually 
follow  it  jKiri  passu  with  the  reflex  manifestations.  The  feet  and  legs 
feel  heavy,  clumsy,  and  weak.  This  paresis  becomes  more  and  more 
pronounced  as  the  pressure  increases ;  the  spastic  gait  is  developed,  and 
finally  the  patient  becomes  bedridden.  Absolute  motor  loss  is  the  great 
exception  and  depends,  like  complete  reflex  obliteration  below  the  lesion, 
upon  division  of  the  cord, 

With  the  motor  loss,  again,  there  is  usually  blunting  of  cutaneous 
sensation,  and  finally  complete  anesthesia,  of  paraplegic  distribution, 
surmounted  by  the  hypersensitive  band. 

To  again  follow  Starr,  the  order  in  which  these  symptoms  arise  is 
commonly  :  (1)  Peculiar  pains  of  limited  distribution  ;  (2)  increase  of 
reflexes  below  the  lesion  ;  (3)  paraplegia  ;  (4)  loss  of  sensibility,  and  (5) 
loss  of  all  subjacent  reflexes.  Bedsores  and  dystrophic  joint-disturbance 
occur  late  in  tumor,  or  may  appear  earlier  upon  the  addition  of  an  acute 
myelitis. 

Course  and  Prognosis. — The  course  of  the  disease  is  usually  slow 
from  the  insidious  onset  to  the  fatal  termination  by  exhaustion  due  to 
pain,  or  the  consequences  of  myelitis,  cystitis,  pyelonephritis,  bedsore, 
and  septicemia.  The  rapidity  of  the  disease  depends  upon  the  char- 
acter of  the  growth,  but  tubercle  is  frequently  of  unexpected  activity 
and  may  induce  a  complete  paraplegia  within  a  few  weeks.  In  rare 
instances  years  have  been  consumed  in  the  development  of  the  tumor. 
The  natural  tendency  is  to  pai-aplegia  and  death.  The  location  of  the 
tumor  in  the  cervical  or  lumbar  enlargement  hastens  the  course  of  events- 

^  "Am.  Jour.  Med.  Sciences,"  June,  1895. 


INDISCRIMINATE  CORD   LESIONS.  371 

The  prognosis  in  tumor  involving  the  cord,  excepting  gumma,  is  uni- 
formly bad,  and  ])raetically  fatal  without  operation. 

Diagnosis. — The  diagnosis  of  cord-tumor  depends  mainly  upon  the 
insidious  onset  and  the  order  of  development  of  symptoms.  The  slow- 
compression  of  the  cord  gradually  induces  the  paraplegic  state  with, 
intense  spasticity,  but  is  preceded  by  the  localized,  persistent,  and  uni- 
form root  or  segment  pains.  A  cross-myelitis  is  ordinarily  of  sudden 
onset  and  not  especially  painful  unless  the  meninges  are  affected.  In 
that  event  the  pain  is  diffuse  and  intense  over  the  spine.  Bedsores  and 
trophic  disturbance  are  early  features  of  myelitis,  late  ones  of  tumor. 
The  presence  or  history  of  new  growths  elsewhere  aids  the  diagnosis^ 
and  the  location  in  the  dorsal  cord  is  of  some  significance.  In  Potfs 
disease  we  soon  have  rigidity  of  the  back,  pain  upon  rotation  or  percus- 
sion or  jars  of  the  spine,  and  later  vertebral  thickenings  and  defor- 
mities. The  nerves  are  sensitive  and  the  pain  accurately  follows  the 
nerve-trunks  as  a  rule. 

The  location  of  the  tumor  is  deciphered  by  reference  to  the  general 
rules  of  cord-localization,  especial  importance  attaching  to  the  location 
of  the  early  pains  and  the  upper  levels  of  dysesthesia.  As  already  indi- 
cated, it  is  usually  impossible  to  clinically  determine  whether  a  growth 
is  vertebral,  meningeal,  or  cordal,  and  operations  are,  therefore,  to  this 
extent  exploratory.  A  Brown-Sequard  paralysis,  followed  by  a  para- 
plegia, or  analgesia  preceding  anesthesia,  or  limited  early  muscular 
atrophy,  may  indicate  that  the  growth  is  probably  within  the  cord. 

Speculation  as  to  the  nature  of  the  growth  is  based  on  those  general 
features  which  are  common  to  growths  in  all  localities.  The  presence 
of  malignant  growths  elsewhere  points  to  a  secondary  neoplasm  of  the 
same  order.  Tuberculosis  and  syphilis  have  their  own  indications.  It 
may  also  be  borne  in  mind  that  sarcoma  is  the  most  common  form 
of  tumor  in  this  location. 

Treatment. — With  the  exception  of  gummata,  which  are  to  a  con- 
siderable degree  amenable  to  antisyphilitic  treatment,  the  only  course 
that  promises  relief  is  surgical  operation.  It  is  evident  that  tumor  with- 
in the  cord-substance  can  not  be  removed  without  great  and  permanent 
damage  to  the  cord.  It  is  also  evident  that  if  the  compression  from 
without  has  caused  local  cord-disintegration,  an  operation  can  at  best 
only  check  the  harm  at  that  particular  stage.  Malignant  neoplasms 
are  very  likely  to  recur,  and  are  frequently  secondary  to  large  growths 
elsewhere  that  have  already  jeopardized  life.  Tubercle  is  also  often 
secondary  to  a  process  that  may  leave  little  hope  of  prolonged  existence. 
The  fact,  however,  remains  that  without  removal  the  cord-tumor  itself 
will  induce  a  fatality,  preceded  usually  by  the  most  intense  suffering  and 
the  most  abject  helplessness.  Even  when  an  operation  can  do  nothing 
but  relieve  the  pains  due  to  the  local  irritation,  it  may  be  favorably  con- 
sidered. 

On  the  other  hand,  about  seventy  per  cent,  of  recorded  cases  were 
operable,  and  out  of  thirty- three  operated  cases,  tabulated  by  Putnam 
and  Warren,!  over  one-half  resulted  successfully.  Similar  figures  are 
1  "Am.  Jour.  Med.  Sciences,"  Oct.,  1899. 


372  DISEASES  OF  THE  COED  PROPER. 

given  by  Starr  and  also  by  Bruns.^      Early  diagnosis  and  prompt  oper- 
ation will  materially  improve  the  average. 

SPINA  BIFDDA. 

Spina  bifida  is  an  embryological  defect  due  to  the  failure  of  the  neural 
canal  to  completely  close  in  the  posterior  median  line.  As  a  result^  the 
bony  arches  of  the  vertebrae  are  defective.  This  may  be  indicated  by  a  de- 
pression, spina  bifida  occulta,  or  by  a  tumor  made  up  of  the  contents  of  the 
spinal  canal  variously  arranged.  Its  usual  location  is  in  the  lumbosacral 
region,  as  the  neural  canal  closes  from  above  downward  and  is  last  com- 
pleted at  the  caudal  extremity.  When  present,  it  serves  to  fix  the  lower  end 
of  the  cord  to  the  corresponding  vertebrae,  and  the  normal  recession  of  the 
conus  medullaris  to  the  level  of  the  second  lumbar  vertebra  is  prevented. 

The  simplest  variety  is  the  rare  meningocele,  which  is  usually  covered 
by  skin  and  consists  of  a  pediculate  or  pedunculate  sac  of  spinal  mem- 
branes continuous  with  the  arachnoid  spaces.  Neither  the  cord  nor  the 
nerves  enter  it,  and  deformities  of  the  cord  or  disabilities  in  the  legs  and 
sphincters  are  absent. 

The  ordinary  tumor  in  spina  bifida  is  the  meningomyelocele,  made  up 
of  both  the  cord  and  the  meninges  and  usually  attended  by  deformities 
and  paralysis  in  the  legs  and  sishincters.  The  cord  ordinarily  is 
flattened  out  in  the  posterior  surface  of  the  tumor,  which  is  more  or 
less  translucent,  devoid  of  true  skin,  and  only  covered  by  a  layer  of 
epithelium.  From  this  posterior  situation  the  flattened  and  deformed 
cord-substance  gives  ofl^  the  nerve-roots,  which  run  forward  through  the 
sac  into  the  intervertebral  foramina.  In  the  most  prominent  part  of  the 
tumor  corresponding  to  the  cutaneous  defect  and  the  location  of  the 
broadly  spread  cord-substance  there  is  often  a  pit  or  umbilical  depression. 

In  rare  and  more  pronounced  deformities  the  central  canal  of  the  cord 
dilates  with  the  tumor  formation,  hydromyelocele,  and  lines  its  cavity, 
with  which  it  is  coextensive.  The  nerve-roots  now  lie  in  the  sac-walls. 
Again,  in  myelocele  a  flattened  mass — not  a  sac — of  neural  tissue  lies  in 
the  vertebral  hiatus,  containing  a  small  opening  leading  into  the  cerebro- 
spinal canal.  Through  this,  cerebrospinal  fluid  constantly  oozes.  Both 
of  these  forms  are  rare,  always  attended  by  defects  in  the  lower  extrem- 
ities, and  the  latter,  myelocele,  is  promptly  fatal  in  a  few  days. 

Etiology. — The  causation  of  this  defect  in  the  embryo,  which 
dates  back  to  the  earliest  days  of  impregnation,  like  similar  terato- 
logical  defects,  is  obscure.  It  has  been  attributed  to  injury.  In  a 
number  of  instances  it  has  appeared  in  several  children  in  the  same 
family,  and  even  in  succeeding  generations,  showing  hereditary  trans- 
mission. Other  children  in  the  same  family  may  present  harelip  or 
club-foot.  It  is  more  common  in  females  than  in  males,  in  a  ratio  of 
about  eight  to  seven. 

Symptoms. — Spina  bifida  is  usually  discovered  at  birth,  but  may 

■exist  unnoticed  as  a  slight  depression,  often  covered  by  hair  for  months 

ov  even  up  to  adolescence,  when  the  tumor  may  appear.     At  first  usually 

small  in  size,  it  may  rapidly  increase.     When  the  cord  is  involved  in 

1  "Die  Geschwiilste  des  Nerven-Systems. " 


INDISCRIMINATE   CORD  LESIONS.  373 

tlie  sac,  there  is  usually  associated  club-foot  or  undeveloped  legs  or 
sphincteric  incontinence.  The  tumor  is  in  the  middle  line  and  presents 
varying  appearances  due  to  its  makeup.  The  opening  in  the  vertebral 
arches  can  usually  be  detected  by  touch,  but  the  contents  of  the  tense, 
fluctuating,  and  slightly  compressible  sac  are  rarely  palpable.  Under 
excitement  and  in  the  erect  positicju  t\fb  sac  increases  in  tension  and  size. 
Pressure  upon  it  is  likely  to  produce  uneasiness,  stupor,  coma,  and  con- 
vulsions. The  fluid  contents  correspond  to  and  are  identical  with  cere- 
brospinal fluid. 

The  diag-nosis  is  usually  very  easy,  but  it  is  more  difficult  to  decide 
upon  the  exact  nature  of  the  tumor's  makeup.  The  presence  of  defor- 
mities or  paralysis  in  the  limbs  or  of  sphincteric  incapacity  and  umljili- 
cation  would  indicate  that  the  tumor  was  not  a  simple  meningocele,  but 
that  the  cord  was  involved  in  the  sac-wall.  An  oozing  aperture  and  a 
nevus-like  mass  of  pinkish  tissue  would  suggest  myelocele. 

Prognosis. — Only  in  the  slighter  forms  of  spina  bifida  is  the  progno- 
sis favorable.  A  pedunculated  meningocele  or  mere  depression  is  not 
incompatible  with  full  vitality  and  perfect  cord-functions.  In  the 
severer  varieties,  if  the  child  lives,  it  will  probably  bear  club-foot  or 
other  deformity  and  defect.  The  great  majority  of  cases  die  during  the 
first  three  months,  cases  of  myelocele  during  the  first  three  days.  Rare 
cases  have  reached  adult  age  and  beyond. 

Treatment  is  purely  surgical.  In  meningocele  a  fair  prospect  is 
offered  to  extirpation  of  the  sac.  In  the  other  and  more  common  varie- 
ties, to  extirpate  the  sac  or  to  obliterate  it  by  injections  is  to  destroy  a 
portion  of  the  cord-substance.  In  this  condition  the  sac  must  be  pre- 
served, and  various  osteoplastic  operations  have  been  suggested  looking 
to  the  formation  of  a  bony  neural  canal  covered  by  cutaneous  flaps. 
The  deformities  in  the  lower  extremities  and  the  paraplegic  condition,  of 
course,  would  not  be  benefited  thereby. 


374  DISEASES  OF  THE  COED  PEOPEB. 


CHAPTER  III. 

LESIONS  PRINCIPALLY  CONFINED  TO  THE  GRAY 
MATTER  OF  THE  CORD,  AND  DISEASES  REFERABLE 
TO  DISORDER  OF  THE  SPINAL  GRAY. 

Ix  this  chapter  a  number  of  diseases  are  brought  together  that  have 
in  common  symptoms  dependent  upon  disorder  of  the  lower  motor 
neuron.  In  some,  anatomical  changes  are  clearly  defined  ;  in  others 
there  is  reasonable  presumption  that  eventually  changes  will  be  detected. 
The  whole  question  of  progressive  muscular  atrophy  is  in  a  transitional 
state,  with  a  decided  tendency  to  bring  the  various  forms  into  close 
relationship. 

ACUTE  ANTERIOR  POLIOMYELITIS. 

Poliomyelitis  anterior  acuta,  acute  spinal  para/j/sis,  acute  atrophic 
2)aralysis,  spnnal  paralysis  of  children,  and  essential  pjaraly sis  of  children 
are  the  principal  of  the  numerous  names  applied  to  an  acute  myelitis 
involving  mainly  the  anterior  horns  of  gray  matter  of  the  spinal  cord 
and  commonly  appearing  in  children.  It  is  marked  by  febrile  and 
infectious  symptoms,  is  of  rapid  onset  and  development,  and  promptly 
induces  wide-spread  muscular  paralysis,  a  portion  of  which  commonly 
remains  permanently  and  is  then  attended  by  local  atrophy. 

Etiolog-y. — The  great  majority  of  cases  occur  before  the  tenth  year, 
and  fully  three-fifths  under  four  years  of  age,  with  especial  frequency  in 
the  latter  half  of  the  first  year.  During  the  first  six  months  it  is 
^extremely  rare  or  else  passes  undetected  to  a  fatal  end.  It  has  been 
freelv  attributed  to  dentition,  to  cold,  and  to  traumatism,  especially  in  the 
form  of  falls,  but  it  is  doubtful  whether  any  of  these  alleged  causes  are  of 
direct  importance.  In  many  instances  it  occurs  in  the  course  of  or  dur- 
ing the  convalescence  from  infectious  fevers,  especially  the  exanthemata. 
Its  infectious  nature  is  further  indicated  by  the  abrupt  onset,  the  usual 
febrile  movement,  the  gastric  disturbance,  the  occasional  occurrence  of 
convulsions,  and  most  of  all  by  epidemic  and  endemic  outbreaks.  Such 
have  been  recorded  by  Colmer,i  Cordier,^  Medin,^  Leegard,^  Oxholm, 
Nonne,  Calverly,^  Altman,^  and  others.  In  some  of  these  outbreaks 
a  considerable  variation  from  the  ts^pe  has  been  noticed.  Some  cases 
presented  the  symptom  complex  of  Landry's  paralysis,  with  the  infec- 
tious nature  of  which  we  are  already  familiar  ;  others  evidence  of  acute 
polioencephalitis  superior  and  inferior  (see  p.  151).  If  a  neuropathic 
heredity  counts  for  anything,  it  is  in  the  vulnerability  of  the  central 
nervous  organs  in  certain  individuals. 

Morbid  Anatomy. — The  microscopical  appearances,  as  well  as  the 
finer  changes,  vary  greatly  with  the  age  of  the  lesion.     The  early  de- 

1  "  Am.  Jour.  Med.  Sciences,"  1843.  ^  u  Lyon  Medicale,"  1888. 

3  "Hvo-iene,"  1890.  *  "  Neurolog.  Centralblatt,"  1890. 

*  "  N.  Y.  Med.  Eecord,"  1894.  ®  "  Australian  Med.  Gaz.,"  1897. 


LESIONS  AND  DISEASES  OF  SPINAL    GRAY. 


375 


scriptions  based  on  recovered  cases  were  misleading.  At  the  end  of 
one  or  two  months  a  focus  or  several  foci  of  myelitis  are  found  in  the 
anterior  gray.  There  is  local  destruction  of  nerve-tissue,  with  dilata- 
tion and  changes  in  the  vessels.  The  ganglion-cells  of  the  anterior 
horn  involved  in  the  lesion  have  lost  their  prolongations,  show  granular 
disintegrations,  or  have  entirely  disappeared.  The  myelitic  focus  occu- 
pies one  or  both  of  the  two  arterial 
areas  of  the  anterior  horn  ;  namely, 
that  area  supplied  by  the  first  branch 
of  the   anterior    median    artery    or 


Fig.  137.— Diagram  of  arterial 
meclianism  producing  infantile  par- 
alysis (Williamson). 


Fig.  138. — Section  of  spinal  cord  in  a  case  of 
acuteauteriorpoliomyelitisof  the  adult,  a,  a,  Dilated 
vessels  surrounded  by  round  cells  (Williamson). 


that  field  supplied  by  the  arteries  which  enter  the  cord  along  the  anterior 
roots,  or  both.  Rarely  it  extends  backward  in  the  middle  arterial  field 
and  invades  the  neck  of  the  posterior  horn,  and  usually  it  embraces  the 
adjoining  white  matter  of  the  cord  to  a  varying  extent.  It  is  evident 
that  the  lesion  is  not  strictly  systematized,  and  it  is  equally  evident  that 


Fig.  139. — 1,  Section  of  cervical  cord  in  an  old  ease  of  infantile  paralysis.  The  right  half  is  shrunken 
in  all  its  extent  (Charcot).  2,  Lumbar  section  in  a  case  of  infantile  palsy:  a,  Focus  of  old  inflamma- 
tion ;  left  half  of  cord  shrunken. 

it  is  vascular.  A  contention  has  arisen  as  to  whether  the  lesion  is  first 
parenchymatous,  as  Charcot  claimed,  or  is  first  interstitial,  as  insisted 
upon  by  Goldscheider,  Redlich,  and  others.  The  present  weight  of 
authority  points  to  invasion  by  the  blood-vessels,  interstitial  dissemina- 
tion, and  cellular  destruction  as  the  natural  order  of  events. 

The  myelitic  foci  vary  in  extent  and  number  in  various  cases.   Some- 


376  DISEASES  OF  THE   CORD  PROPER. 

times  they  extend  through  several  segments  of  the  cord,  eight  or  ten 
centimeters  or  more  in  a  vertical  direction,  but  usually  are  one  to  two 
centimeters  in  longitudinal  extent.  Sometimes  single,  more  frequently 
there  are  several  foci  either  on  the  same  or  on  opposite  sides  of  the  cord 
and  at  various  levels.  They  may  even  invade  the  medulla,  and  the 
brain  is  not  absolutely  exempt. 

In  cases  of  many  years'  standing  the  cord  is  seen  to  be  shrunken  on 
one  side  at  the  level  of  the  lesion  and  the  cross-section  is  lacking  in 
symmetry.  The  acute  inflammatory  condition  has  long  disappeared  and  a 
fibroid  condition  alone  represents  it.  Nerve-fibers  and  cells  are  entirely 
destroyed.  The  absence  of  myelinated  fibers  renders  the  scarred  area 
more  or  less  glossy  and  translucent  to  the  naked  eye.  The  vessels  are 
thickened  and  appear  more  numerous  on  that  account.  The  shrinking 
of  the  lateral  half  of  the  cross-section 
involves  mainly  the  gray  matter  and 
especially  that  of  the  anterior  horn,  but 
the    white    columns    and    the    posterior 


Fig   140.— Case  of  polioiuyehus  af-  Fig.     141.- Case    of     poliomyelitis 

fectmg  the  lower  extremities  unequally  ;  afiFecting  right  face  (rare),   right  arm 

foot-drop  on  both  sides.     Note  the  wast-  and  shoulder.  ' 

ing  of  the  right  leg  and  thigh. 

cornu  may  also  share  in  it  to  some  extent.  If  the  original  lesion 
is  sufiiciently  extensive  to  involve  the  spinal  apparatus  of  an  entire 
extremity,  or  even  of  a  segment  of  it,  changes  in  the  cord  above  the 
lesion,  and  in  the  brain,  are  found  analogous  to  those  induced  by  ampu- 
tations. 

The  anterior  roots  arising  from  the  injured  part  of  the  cord  are  often 
diminished  in  volume  and  may  or  may  not  show  alteration  of  structure. 
This  is  true  equally  of  the  mixed  nerve-trunks.  The  exact  condition 
depends  apparently  upon  the  age  of  the  lesion  and  the  complete  or 
partial  disappearance  of  the  peripheral  prolongations  of  the  spinal 
pyramidal  cells  that  have  been  injured.  In  the  paralyzed  muscles  we 
have  the  same  changes  that  are  found  after  division  of  the  nerve-trunk, 
but  a  few  muscular  fibers  often  persist,  some  of  which  may  even  show 
hypertrophy.      The  rest  of  the  muscle  is  fibrous  and  fatty.     Infiltra- 


LESIONS  AND  DISEASES  OF  SPINAL   GRAY.  377 

tion  of  fat  sometimes  reaches  a  condition  that  may  properly  be  desig- 
nated liponiatous.  The  bones  in  the  paralytic  members  are  retarded  in 
their  growth,  and  in  old  cases  dating  from  childhood  are  undersized  in 
comparison  with  those  of  the  sound  side.  They  lack  the  sharply  defined 
muscular  markings,  and  the  Haversian  systems  are  found  to  be  under- 
sized and  poorly  developed. 

Symptoms. — Usually  without  apparent  definite  provocation  the 
child  is  found  to  be  feverish  and  ill.  A  teinperatureoi  100°  to  102°  F. 
has  been  frequently  noted,  and  this  febrile  inv^asion  stage  lasts  from  a 
few  hours  to  several  days,  when  paralysis  and  flacciditi/  of  one  or  more 
limbs  are  detected.  It  is  not  rare,  however,  for  the  child  to  go  to  bed 
apparently  well  and  to  awake  paralyzed  in  the  morning.  The  febrile 
movement  may  be  attended  by  vomiting  and  diarrhea,  by  convulsions  of 
a  generalized  character,  or  by  delirium  and  diffuse  cerebral  manifesta- 
tions. As  soon  as  the  paralysis  is  noted,  the  case  is  usually  recognized. 
Most  writers  state  that  there  is  a  complaint  of  pain  in  the  afflicted 
members  only  rarely,  but  that,  as  a  rule,  sensation  in  all  its  phases  is 
entirely  normal.  It  is  probable,  however,  that  early  dysesthesia,  OAving 
to  the  usual  infantile  age  of  the  patient  and  a  lack  of  careful  search 
for  such  difficulty,  has  been  frequently  overlooked.  In  some  con- 
siderable number  of  cases  handling  of  the  affected  limbs  during  the 
initial  fever  provoked  outcries  which  were  not  elicited  by  similar 
manipulation  of  the  other  members.  It  is  likely  that  more  attention  in 
this  direction  will  show  localized  hypersensitiveness  or  some  kindred 
state  to  be  usually  present  and  of  diagnostic  importance.  Indeed, 
complaints  of  pain  and  of  formication  have  been  generally  noted  in 
older  children  and  in  adults,  lending,  perhaps,  undue  weight  to  the 
usual  supposition  that  such  cases  are  not  of  a  true  spinal  type.  The 
sphincters  are  seldom  relaxed,  so  that  control  of  the  bladder  and 
bowel  remains  unimpaired,  but  in  the  rare  cases  in  which  the  sphincters 
are  relaxed  there  is  more  or  less  apparent  loss  of  sensation,  the 
extent  of  the  lesion  is  greater,  and  the  prognosis  is  extremely  unfavor- 
able. 

Even  in  fat  children  the  implicated  muscles  can  be  seen,  after  a  few 
weeks,  to  have  wasted,  and  if  tested  with  the  faradic  current,  either  do 
not  respond  at  all  or  show  a  remarkable  diminution  in  their  excitability. 
At  this  time  the  patient  will  have  begun  to  show  considerable  improve- 
ment, the  motor  paralysis  remaining  complete  only  in  the  parts  that 
are  to  suffer  permanently,  and  a  gradual  improvement  may  be  expected 
to  extend  over  several  months.  In  the  muscles  showmg  lessened 
faradic  excitability  galvanism  commonly  produces  exaggerated  responses, 
as  compared  with  the  sound  limbs,  and  the  complete  reaction  of 
degeneration  or  any  modification  of  it  may  be  encountered.  In  a  well- 
marked  case  faradism  fails  by  the  tenth  day,  and  the  increased  galvanic 
response  appears,  lasting  for  about  six  months,  when  it  gradually  fails. 
At  this  point  faradic  excitability  returns  and  the  muscle  regains  some- 
thing of  its  size  and  strength  ;  or,  if  too  seriously  impaired,  faradic 
response  does  not  reappear,  galvanic  response  disappears,  and  the  muscle 
is  irretrievably  lost. 

The  reflexes  are  lessened  or  abolished  in  proportion  as  the  muscles 


378 


DISEASES  OF  THE   CORD  PROPER. 


which  are  anatxDmically  associated  with  them  are  involved,  or  perhaps  it 
would  be  better  to  say  that  their  alteration  depends  upon  the  implication 
of  the  cornual  cells  making  up  a  part  of  their  arc.  Bones  which  have 
not  attained  their  full  growth  are  retarded  or  entirely  fail  to  develop  if 
their  trophic  centers  are  implicated. 

The  seriously  atrophied  muscles  become  fibrous  bands,  and,  since  they 
offer  neither  assistance  nor  opposition  to  the  synergic  and  antergic  mus- 
cles, distortions  soon  develop,  with  joint-changes  and  sometimes  subluxa- 
tions. Joints  which  depend  upon  muscular  support,  as  the  shoulder, 
may  allow  of  so  much  deformity  by  the  relaxation  of  the  muscles  which 
have  lost  their  tonicity  that  the  articular  surfaces  widely  separate.     The 


Fig.    142.— Deformity  of  foot  after 
lumbar  poliomyelitis  acuta. 


Fig.   143.— Deformity  of   upper  extremity  and 
thorax  after  poliomyelitis  anterior  acuta. 


shin  is  inactive,  often  cold,  and  sometimes  dry  and  scaly,  but  the  atrophic 
conditions  so  usual  in  neuritis  are  practically  absent  and  bedsores  are 
almost  unknown. 

The  lower  extremities  are  affected  about  three  times  as  frequently  as 
the  upper,  and  the  left  leg  twice  as  often  as  the  right.  A  crossed  form, 
in  which  the  upper  extremity  on  one  side  is  involved  with  the  opposite 
lower  limb,  is  not  rare  ;  but  involvement  of  both  limbs  on  the  same  side 
is  extremely  uncommon.  In  the  loicer  extremity  the  extensors  seem  more 
susceptible  than  the  flexors  ;  hence  drop-foot,  with  talipes  equinus,  flexed 
knee,  and  flexed  thigh  are  common.  When  the  paralysis  is  below  the 
knee,  the  sural  muscles  usually  escape.     In  the  upper  extremity  the  most 


LESIONS  AND  DISEASES   OF  SPINAL    GRAY.  379 

frequently  encountered  wasting  is  in  the  small  muscles  of  the  hands,  the 
deltoid,  and  the  extensors  of  the  wrists.  The  biceps  and  supinators 
generally  escape. 

The  distribution  of  the  paralysis  of  muscles  follows  their  segmental 
relations  in  the  cord,  and,  consequently,  when  limited  is  of  a  functional 
character.  The  very  fact  of  such  functional  distribution  at  once  incrimi- 
nates the  cord.  The  muscles  of  the  trunk  are  in  rare  cases  notably  and 
Avidely  aifected,  producing  weakness  in  the  back,  deviation  of  the  spinal 
column,  and  defects  in  the  muscles  of  the  chest.  Ordinarily,  however, 
the  seoinents  of  the  cervical  and  lumbar  enlargements  are  selected.  A 
small  focus  of  anterior  poliomyelitis  in  the  dorsal  region  hardly  pro- 
duces local  signs,  as  the  trunk  and  thoracic  muscles  are  represented  in  a 
considerable  vertical  extent  of  the  cord. 

The  bulbar  muscles  do  not  always  escape,  as  is  shown  by  various 
ophthalmoplegias,  squints,  facial  and  hypoglossal  palsies,  which  are  now 
and  then  recorded,  and  would  be  more  often  seen  did  not  coincident 
pneumogastric  accidents  usually  terminate  such  cases  fatally. 

Course  and  Forms. — The  course  of  the  disease  may  be  clinically 
divided  into  :  (1)  A  stage  of  febrile  invasion,  lasting  from  a  few  hours  to 
several  days,  with  local  tenderness  and  rapidly  developing  and  increasing 
paralysis  ;  (2)  a  stationary  stage,  lasting  for  several  weeks ;  (3)  a  period 
of  improvement,  lasting  to  the  end  of  a  year,  and  (4)  a  stage  of 
permanent  disability  for  the  remainder  of  life.  Relapses  during  the 
early  weeks  have  been  recorded  in  very  rare  instances,  and  second 
attacks  are  still  rarer.  Among  the  sequelae  the  contractures,  disloca- 
tions, and  deformities  have  been  already  mentioned.  The  fragility  of 
the  bones  makes  them  liable  to  fracture,  but  union  takes  place  with  ordi- 
nary promptness  under  proper  fixation. 

The  adult  form  is  in  no  way  diiferent  from  the  infantile  cases,  except- 
ing the  variations  due  to  complete  growth  having  been  attained.  In 
anomalous  cases  the  onset  of  the  disease  is  insidious  and  the  course  may 
be  subacute.  After  infectious  diseases  one  or  more  limbs  may  be  found 
useless,  flaccid,  and  atrophic,  declaring  the  antecedent  myelitis.  Occa- 
sionally the  onset  is  marked  by  pains  of  a  severe,  cutting  character, 
which  are  frequently  attributed  to  neuritis  or  to  rheumatism,  but  may 
be  due  to  the  irritation  of  the  sensory  pathway  in  the  cord  by  the  loca- 
tion of  the  myelitic  focus  backward,  involving  the  neck  of  the  posterior 
horn. 

It  has  been  noted  by  a  number  of  observers  that  in  rare  instances, 
years  after  the  acute  disease  has  subsided,  a  slow,  insidious  reappear- 
ance has  led  to  a  progressive  muscular  atrophy,  which  declares  itself  first 
in  the  limbs  that  were  originally  paralyzed  by  the  acute  process,  but 
had  apparently  fully  recovered.  This  may  progressively  invade  the 
entire  muscular  system. 

Diagnosis. — In  the  early  stages  of  fever,  before  paralysis  has 
appeared,  diagnosis  usually  fails  except  under  rare  epidemic  conditions. 
The  termination  of  an  apparently  trivial  ailment  in  extensive  paralysis 
is  frequently  the  cause  of  much  chagrin  on  the  part  of  the  medical 
attendant,    who    may    naturally    enough    have    expressed    a    favorable 


380  DISEASES  OF  THE   COED  PROPER. 

prognosis.  As  already  indicated,  the  initial  fever  may  be  readily  mis- 
taken for  that  of  general  disorders,  and  sometimes,  thongh  rarely, 
the  pain  in  the  limbs  leads  to  the  idea  of  rheumatism.  If,  however, 
the  possibility  of  anterior  poliomyelitis  be  in  mind,  and  examination 
discloses  some  slight  local  tenderness  or  diminished  muscular  activity,, 
or  both,  a  guarded  opinion  will  naturally  follow.  It  is  only  when  the 
paralysis  is  developed  or  developing  that  the  nature  of  the  disease 
becomes  certain,  and  even  then,  if  there  have  been  cerebral  symptoms,. 
Buch  as  delirium  or  convulsions,  difficulties  are  not  at  an  end.  The 
Gerebral  palsy  of  children  is  almost  invariably  ushered  in  by  convul- 
sions, but  these  have  a  definite  distribution  involving  one  side  or  one 
limb,  or  only  the  face,  while  the  convulsions  of  the  disease  under  con- 
sideration are  generalized.  Localized  pain,  from  hxvumatism  or  inflam- 
mation, may  cause  immobility  of  a  limb,  and  when  preceded  by  fever 
gives  rise  to  a  doubt ;  but  the  usual  absence  of  extreme  sensory  disturb- 
ances in  disease  of  the  anterior  horns  is  a  distinguishing  feature,  while 
the  local  conditions  can  be  otherwise  made  out.  After  a  few  days  the 
electrical  test  gives  absolute  data.  Faradic  response  is  abolished  in  no 
other  disease  so  early  ;  even  in  severe  neuritis  it  is  longer  maintained, 
and  is  then  attended  by  a  very  marked  sensory  disturbance,  which  also 
usually  precedes  it  for  a  long  time.  A  few  careful  applications  of  the 
induced  current  at  this  period  can  do  no  harm.  The  progressive  infan- 
tile myopatkies  are  of  extremely  slow  development  and  are  symmetrical 
in  distribution. 

Prog-nosis. — So  far  as  life  is  concerned,  this  disease  terminates 
fatally  only  exceptionally,  and  if  the  patient  survives  the  onset  of  the 
paralysis  but  a  short  time,  life  may  be  considered  out  of  danger. 
Further,  one  can  say,  with  a  reasonable  degree  of  certainty,  that  the 
paralysis  at  first  developed  will  notably  recede,  but,  unfortunately,  it  is 
almost  equally  certain  that  a  portion  of  it  will  permanently  remain. 
At  the  end  of  a  fortnight  a  carefully  conducted  faradic  examination  of 
the  muscles  enables  the  physician  to  sj3eak  more  specifically  regarding 
the  amount  of  permanent  disability.  At  that  time  any  muscle  which 
responds,  however  feebly,  may  be  expected  to  regain  a  fair  degree  of  its 
former  tone  and  strength.  Even  after  several  months,  repeated  faradic 
stimulation  of  a  muscle,  at  first  perfectly  inactive,  may  develop  some 
contractility,  and  this  is  of  favorable  import  for  the  given  muscle.  The 
extent  of  permanent  paralysis  governs  the  amount  of  resulting  con- 
tracture and  deformity ;  and,  likewise,  the  retardation  of  development 
of  the  limb  and  of  the  bones  is  in  similar  relation.  The  anticipated 
amount  of  these  deforming  conditions  will  have  a  bearing  on  the  prob- 
able general  activity  of  the  individual,  his  prospective  physical  health,, 
and  liability  to  fractures.  The  possibility  of  the  late  appearance  of  a 
progressive  muscular  wasting  may  be  kept  in  mind. 

Treatment. — Owing  to  the  irregularities  of  the  course  of  this  dis- 
ease in  various  cases,  and  its  natural  tendency  to  improve  up  to  a  certain 
point,  it  becomes  a  matter  of  great  difficulty  to  estimate  the  value  of 
any  therapeutic  agent  or  mode  of  treatment.  In  the  early  stage,  as 
soon  as  the  diagnosis  is  made,  if  fever  still  continues,  there  is  good  rea- 


LESIONS  AND  DISEASES  OF  SPINAL   GEAT.  381 

son  to  suppose  that  antipyretic  antiseptics,  like  the  saKcylates,  large 
doses  of  the  tincture  of  the  chloric!  of  iron,  or  even  bichlorid  of  mer- 
cury, would  do  good.  Hot  applications  can  be  made  to  the  spine  if  the 
circumstances  of  the  patient  will  insure  their  intelligent  and  faithful 
employment ;  otherwise  they  are  worse  than  useless,  and  very  mild 
sinapisms  can  be  more  properly  used.  The  child  should  be  kept  on 
the  side  or  face,  and  the  affected  limbs  should  be  thoroughly  enveloped 
in  cotton-wool  to  maintain  the  circulation  and  the  nourishment  of  the 
muscles  in  the  parts  laboring  under  diminished  trophic  influence. 
The  use  of  spinal  stimulants  like  strychnin  while  the  lesion  is  active 
is  to  be  avoided ;  but  when  the  active  process  has  come  to  a 
standstill, — that  is,  ordinarily,  at  the  end  of  a  fortnight, — its  systematic 
use  is  one  of  the  most  important  measures.  The  usefulness  of  electricity 
consists  of  maintaining  the  nourishment  and  normal  contractility  of  the 
muscles,  which  are  temporarily  deprived  of  their  natural  motor  and 
trophic  control,  so  that,  as  the  inflammation  subsides  and  the  wide-spread 
inhibitory  effect  of  the  local  lesion  recedes,  the  central  apparatus  may 
find  the  muscular  periphery  in  the  most  favorable  state  to  respond  to 
its  enfeebled  influence.  For  this  purpose,  as  the  faradic  response  is 
early  abolished,  the  interrupted  galvanic  current  must  be  used,  the 
slightest  intensity  being  employed  that  will  cause  a  contraction.  Care 
must  be  taken  not  to  unduly  fatigue  the  muscles.  A  dozen  contractions 
at  most  should  be  elicited  at  one  seance,  and  often  only  one  or  two  can 
be  provoked  by  any  strength  of  current  that  is  bearable.  Care  not  to 
alarm  the  child  is  imperative,  as  a  daily  struggle  will  do  more  harm, 
probably,  than  the  electricity  will  do  good.  As  the  muscles  often 
react  better  and  with  less  pain  to  the  positive  pole  than  to  the  negative, 
it  is  well  to  have  for  the  negative  electrode  a  broad  sponge  which  may 
be  placed  on  the  sacrum  or  breast,  and  with  a  smaller,  positive  sponge 
the  muscles  may  be  exercised.  Applications  of  galvanism  through  the 
cord  are  quite  useless,  and  even  if  such  currents  reached  the  lesion, 
which  is  doubtful,  their  effect  for  good  is  questionable. 

Later  on,  as  faradic  response  returns  in  the  muscles  only  slightly 
affected  or  temporarily  inhibited,  this  form  of  electricity  is  efficacious 
for  the  purpose  of  local  stimulation,  and  the  presence  of  this  reaction 
in  any  muscle  is  always,  as  already  indicated,  a  gratifying  circumstance. 
To  intrust  galvanic  electrical  treatment  to  the  parents,  however  intelli- 
gent they  may  be,  is  a  mistake. 

In  the  same  way  local  frictions  and  salt  baths,  warm  wrappings, 
and  massage  are  valuable  measures  which  can  be  more  rationally  trusted 
to  parents  or  nurses  who  take  an  intelligent  interest  in  the  work.  They 
may  be  gently  employed  from  the  first  day,  and  when  electricity  is  not 
tolerated  or  can  not  be  systematically  employed,  must  be  relied  upon  to 
replace  it.  The  moment  a  group  of  muscles  weakens,  the  limb  tends  to 
assume  an  abnormal  position,  and  it  is  very  important  to  meet  this 
tendency  from  the  very  first  moment,  even  in  cases  where  there  is  every 
probability  that  the  paresis  will  recede.  It  can  be  easily  accomplished 
by  means  of  the  warm  wrappings,  or  even  by  the  application  of  light 
splints.     There  can  be  no  question  that  recovering  muscles  will  find 


382  DISEASES   OF  THE   CORD   PBOPEE. 

their  task  much  easier  if  their  proper  relations  have  been  maintained. 
Unbalanced  muscles  will  be  much  less  liable  to  contractures  if  an  arti- 
ficial balance  has  been  provided  and  joint-surfaces  have  not  been  altered 
by  long-maintained  vicious  positions. 

As  soon  as  the  permanent  paralysis  can  be  fairly  -svell  foretold, 
massage  should  be  especially  directed  to  obviate  the  contractures  and 
deformities  that  ordinarily  result,  Stretcliing  of  the  unopposed  muscles 
by  passive  movements  of  the  joints  will  accomplish  much,  and  the 
moment  a  tendency  to  contracture  is  perceived,  the  case  becomes  one  for 
mechanical  appliances.  The  tendency  to  talipes  equinus,  for  instance, 
can  be  met  by  a  light  elastic  cord  from  the  toe  of  the  shoe  to  a  band  at 
the  knee ;  and  more  elaborate  orthopedic  apparatus  should  be  employed 
at  the  knee  and  hip  if  required.  These  cases  are,  therefore,  practically 
orthopedic  disorders  from  the  very  first. 

Nearly  all  the  improvement  that  is  to  take  place  in  the  muscles  will 
have  developed  by  the  end  of  the  first  year,  and  what  is  slowlv  sub- 
sequently gained,  seems  independent  of  any  treatment  whatever. 

The  treatment  of  a  late  or  neglected  case  is  practically  surgical. 
Shortened  tendons  may  be  cut  and  joints  straightened.  Tendons  of 
healthy  muscles  may  sometimes  be  transplanted  to  take  the  place  of 
those  paralyzed.  A  resection  at  the  knee  is  sometimes  of  advantage  to 
secure  a  rigid  limb  instead  of  a  useless  contortion  or  a  dangle-leg.  By 
using  a  high  shoe  or  other  appliance  crutches  may  often  be  laid  aside. 
The  arrangement  of  exercises  to  increase  the  strength  of  the  involved 
muscles  which  retain  some  fraction  of  their  muscular  elements  is  of  dis- 
tinct advantage.  By  intelligent  passive  and  active  movements  and  effort 
against  resistance  much  can  be  accomplished. 


SYRINGOMYELIA. 

The  central  canal  of  the  cord  is  sometimes  enlarged  through  congenital 
defect.  This  may  be  a  part  of  a  general  ventricular  distention,  causing 
hydrocephalus  and  spina  bifida.  In  certain  instances  unattended  by  any 
symptoms  during  life  a  tubular  cord  has  been  found  post  mortem.  These 
cases  present  hydromyeli%  and  are  of  teratological  origin.  The  term 
syringomyelia  is  now  limited  to  acquired  enlargement  of  the  central 
canal  or  to  the  for-mation  of  entirely  new  canals  of  considerable  length 
in  the  gray  substance  of  the  cord.  Such  canals  are  the  result  of  glio- 
matous  infiltration  about  the  central  canal  or  in  the  gray  horns  of  the 
cord  and  its  subsequent  degeneration,  forming  tubular,  cystic  cavities. 
In  rare  instances  a  central  myelitis  or  a  central  hemorrhage  may  cause 
a  fusiform  or  tubular  excavation  that  can  not  always  be  clinically  dis- 
tinguished from  the  neoplastic  variety  or  may  in  turn  induce  the  latter. 
Some  cases  probably  originate  in  spinal  hemorrhage  occurring  at  birth. 
About  300  cases  have  been  reported  and  many  more  have  been  obser\'ed. 

Etiolog-y. — Men  are  much  more  frequently  affected  by  this  disease 
than  women,  and  especially  men  exposed  to  hard  labor.  Verhagen  and 
Vandervelde  report  several  instances  of  syringomyelia  in  the  same  family, 
but  a  neuropathic  heredity  is  rare.     Adult  years  furnish  nearly  all  the 


LESIONS  AND  DISEASES  OF  SPINAL    GRAY. 


383 


reported  cases,  but  it  has  been  observed  well  developed  at  nineteen  by 
Langdon,  of  Cincinnati,  1)V  the  author  at  sixteen,  and  by  Ballard  and 
Thomas  at  three.  ^  Cold,  rheumatism,  exposure  to  bad  weather,  trau- 
matism, overwork,  the  acute  infectious  fevers,  and  syphilis,-  have  been 
reported  as  possibly  causative  in  various  cases,  but  this  relation,  in  the 
gliomatous  form,  at  least,  is  entirely  conjectural. 

Morbid  Anatomy. — The  syringomyelic  cord  in  marked  cases  shows 
notable  elianges  of  conformation   that   correspond  to  its  tubular  condi- 


Fig.  144.— Sections  of  a  syringomyelic  cord.    1,  Lower  lumbar  region  ;  2,  upper  lumbar  region*, 
3,  midcervical  region  (Brulil). 


Figs.  14.5  and  146. — Sections  of  two  syringomyelic  cords  showing  common  locations  and  extent  of 

cavities  (Brissaud). 


tion.  It  is  soft,  flattened,  and  sometimes  fluctuating.  The  collapse  of 
the  canal  may  produce  a  furrow,  so  that  the  cord  seems  double.  The 
condition  finds  its  favorite  localit}^  in  the  cervical  region,  but  may  extend 
throughout  the  entire  length  of  the  cord  or  be  confined  to  any  portion 
of  it.     Its  upward  extension  carries  it  into  the  fourth  ventricle. 

The  cross-section  usually  reveals  a  single  oval  cavity,  or  there  may 
be  several  in  communication  or  independent.     The  customary  situation 

1  "Am.  Jour.  Med.  Sci.,"  Mar.,  1899. 

^  Nebelthau,  "  Zeit.  f.  Nen^enh.,"  Feb.,  1900. 


384 


DISEASES   OF  THE  COED  PROPER. 


is  in  the  immediate  neighborhood  of  the  central  canal  and  behind  it, 
but  it  may  extend  laterally  into  the  anterior  or  more  commonly  into  the 
posterior  horn  of  gray  matter,  either  on  both  sides  or  unilaterally. 
Again,  it  may  be  limited  to  one  posterior  horn.  While  the  white  columns 
of  the  cord  may  be  spared,  it  is  not  unusual  for  the  gliomatous  process 
to  invade  them,  especially  the  pyramidal  tract,  when  the  gray  matter 
has  been  widely  destroyed  and  the  cavity  has  attained  large  proportions. 

The  cavity  contains  cerebrospinal  fluid,  M'hich 
is  sometimes  bloody  or  gelatinous.  Its  walls  are 
made  up  of  a  well-defined  substance,  outside  of 
which  the  cord  appears  infiltrated,  dense,  and  even 
sclerosed.  In  the  medulla,  when  the  lesion  extends 
so  high,  the  gray  matter  is  first  similarly  affected. 
The  microscope  shows  the  usual  new  formation 
to  be  gliomatous  and  rich  in  blood-vessels,  especi- 
ally on  the  external  periphery.  The  predomi- 
nance of  various  elements  gives  rise  to  varieties 
such  as  pure  glioma,  neuroglioma,  and  vascular 
glioma,  all  of  which  may  be  present  in  the  same 
cord.  Schultze  describes  an  infiltrating  sort  as  a 
gliosis.  It  does  not  usually  result  in  cavity  form- 
ation, and  is,  therefore,  distinguished  from  the 
gliomatous  variety.  He  is  supported  by  Hoffman, 
and  Holt  and  Harter  ^  report  a  case.  Orlowski  ^ 
has  seen  a  double  canal,  one  arising  from  dilatation 
of  the  central  canal  and  the  other  from  gliosis  and 
degeneration  outside  the  central  canal.  Charcot, 
Hollopeau,  Joffroy,  and  Achard  insist  that  in  some 
cases  the  initial  step  is  a  central  myelitis,  which 
Schultze,  Dejerine,  and  others  deny.  The  nerve- 
tissues  involved  in  these  various  processes  are 
strangled  and  destroyed  even  before  the  formation 
of  cavities.  The  cells  first  yield  their  prolonga- 
tions and  then  disappear.  The  axis-cylinders  out- 
last the  myelin.  The  meninges  and  spinal  roots 
are  usually  unaffected  except  in  the  form  associ- 
ated with  cervical  pachymeningitis.  Destruction 
of  the  anterior  horns  is  followed  by  the  usual 
trophic  disturbance  in  the  associated  periphery, 
such  as  wasted  muscles,  perforating  ulcers,  and 
cutaneous  dystrophy.  The  interference  with  the  cells  of  Clarke's  columns 
is  supposed  to  account  for  the  joint-lesions  that  are  commonly  present, 
and  vv'hich  are  identical  with  the  arthropathies  of  locomotor  ataxia. 

Symptoms. — From  the  nature  of  the  lesion  it  is  apparent  that  the 
symptoms  may  in  different  cases  embrace  perversion  and  obliteration  of 
all  the  various  functions  of  the  cord.  Nevertheless,  their  peculiarities 
and  groupings  are  sufficiently  distinct  to  frequently  enable  a  diagnosis. 
As  there  is  no  common  type,  the  symptoms  must  be  arranged  somewhat 
arbitrarily. 


Fiu.  147. — Case  of  syriu- 
gomyelia  with  areas  of 
theinio-anesthesia  marked 
in  black.  Ttiere  is  cervical 
kyphosis. 


1  "Am.  Jour.  Med.  Sci.,"  April,  1895. 


"Arch,  de  Neurol.,"  Sept.,  1898. 


LESIONS  AXD  DISEASES  OF  SPIXAL  GRAY. 


385 


Sensory  Disturbances. — The  early  iuvolvenient  of  the  sensory  path- 
ways iu  the  gray  commissure  and  in  the  posterior  horns  and  columns 
produces  related  sensory  symptoms  which  are  well-nigh  characteristic. 
There  are  usually  definite  coextensive  areas  of  thermo-anesthesia  and 
analgesia,  with  retention  of  the  tactile  sensibilit\\  This  is  sometimes 
denominated  the  sijrinfjomi/elic  dissociation  of  cutaneous  sensation,  and  is 
highly  important  to  the  diagnosis.  The  patient  fails  to  distinguish  the 
temperature  of  water  or  objects  brought  in  contact  with  the  skin,  though 


Fig.  143. — Various  distributions  of  thermo-anesthesia  and  analgesia  (Brissand). 

recognizing  contact,  and  may  receive  burns  in  this  way  without  expe- 
riencing any  pain.  The  thermo-anesthesia  may  be  complete  or  partial,  and 
is  then  relative  to  the  part  examined  and  somewhat  to  the  patient's  in- 
telligence (see  Part  I).  Sometimes  heat  is  felt  as  pain,  or  "  hot "  as 
"  cold."  The  distribution  of  the  thermo-anesthesia  is  also  significant. 
Rarely  it  may  be  hemiplegic  ;  it  is  seldom  general.  Ordinarily,  it  in- 
volves the  limbs,  or  portions  of  them,  such 
as  would  be  covered  by  a  glove  or  sleeve,  a 
sock  or  long  stocking.  It  may  be  limited 
to  thoracic  or  abdominal  bands.  It  may 
be  unilateral  or  symmetrical.  In  figure 
147  it  is  of  unusual  outline,  but  will  be 
noticed  to  roughly  conform  to  some  spinal 
segments.  In  some  cases  areas  at  first 
discrete  have  been  observed  to  coalesce 
into  anatomical  cord-territories. 

The  analgesia  may  be  partial  or  com- 
plete, and  usually  conforms  in  outline  to 
the  thermo-ane.sthetic  area  or  may  be  more 
extensive.      It  emljraces  all  the  tissues,  so 

that  felons,  caries  of  bone,  and  disintegrating  joints   may  be  painless 
and  insensitive. 

As  a  general  rule,  tactile  sensibility  is  perfect.  A  slight  diminution 
of  it  is  not  inconsistent  with  the  diagnosis,  and  its  obliteration  foUows 
extreme  invasion  of  the  posterior  columns,  being  then  a  part  of  the 
absolute  anesthesia  that  marks  such  a  lesion.  A_n  anesthetic  area  may 
thus  have  a  border  of  thermo-anesthesia  and  analgesia,  or  these  condi- 
tions may  be  found  in  different  parts  of  the  body,  in  relation  to  the 
amount  and  distribution  of  the  cord  disease. 
25 


149. — Thermo-anesthesia  and  anal- 
gesia (Brissand). 


386 


DISEASES  OF  THE  CORD  PROPER. 


i 


in 

of    spinal    origin,    and    their 
is  reduced  in  proportion  to  the 


# 


Motor  disturbances  are  dependent  largely  npon  the  invasion  of  the 
anterior  horns  and  the  pyramidal  tracts.  They  are,  therefore,  usually 
secondary  in  point  of  time  to  the  sensory  symptoms  Avith  which  they  come 
to  be  associated.  As  the  anterior  horn  is  invaded,  the  associated  muscles 
lose  power  and  their  reflexes  diminish  and  disappear.  Some  muscular 
atrophy  is  almost  always  present,  and  it  may  reach  a  high  grade.  Its 
distribution  depends  npon  the  part  of  the  cord  involved,  and  may  con- 
form to  many  of  the  typical  spinal  atrophies,  such  as  the  form  of 
Duchenne-Aran,  for  which  it  has  no  doubt  been  frequently  mistaken. 
It  may  be  progressive   or  advance  by  spurts,  and  is  most  common  in 

the  upper  extremities.  Fibrillar}^  to'itch- 
ing  and  reaction  of  degeneration  mark  the 
atrophic  muscles,  as  in  other  muscular 
atrophic.' 
strength 

atrophy.  AVhen  the  gliomatous  process 
invades  the  lateral  tract,  spastic  features 
are  induced.  These  may  be  associated 
with  disorders  due  to  involvement  of  tlie 
anterior  horn,  producing  the  conditions 
found  in  amyotrophic  lateral  sclerosis,  but 
the  face  is  usually  unafiected.  Involve- 
ment of  the  posterior  columns  causes 
ataxia  and  incoordination. 

Trophic  Features. — The  affected  ex- 
tremities, in  addition  to  the  muscular 
atrophy,  often  present  trophic  disturb- 
ances, especially  about  the  digits,  similar 
to  those  in  neuritis.  Glossy  skin,  hyper- 
trophic nails,  increased  or  diminished  per- 
spiration, and  herpetic  and  bullous  erup- 
tions are  encountered.  Cuts,  Vjurns,  and 
abrasions  heal  badly  or  tend  to  permanent 
ulceration.  In  this  way  paronychia  causes 
the  nails  to  fall.  Felon  is  rather  com- 
mon, especially  in  the  Morvan  t^'jDe,  and 
causes  mutilations  of  the  fingers  hx  the, 
loss  of  several  phalanges,  unattended,  usu- 
ally, by  the  slightest  pain.  Perforating 
ulcer  is  encountered  with  some  frequency.  Boils,  abscesses,  and  other 
local  infections  are  not  rare.  They  all  heal  1)adly,  produce  extensive 
scars,  and  may  cause  mutilations  and  deformities. 

The  arthropathies  are  almost  invariably  represented.  They  affect 
the  spine  by  preference,  and  the  articulations  of  the  upper  extremities 
more  frequently  than  those  of  the  lower  limbs.  In  some  cases  the 
bones  are  affected.  They  are  fragile,  readily  fractured,  and  unite  with 
difficulty  and  with  persisting  callous  deformities.  In  a  few  cases  the 
hands  have  been  enlarged,  as  in  acromegalia,  for  which  this  disease  has 
been  mistaken.     They  have  even  been  found  associated.      The  spinal 


Fig.  150. — Case  of  syringomyelia, 
showing  atrophy  over  right  scapula 
and  thorax  and  in  right  leg.  Spine 
scoliotic. 


LESIONS  AND  DISEASES  OF  SPINAL  GBAY.  387 

artlu'opathies  give  rise  to  deviations  of  the  vertebral  cokmiu  in  over 
oiie-iialf  of  the  cases.  Usually  it  is  a  scoliosis,  but  angular  deformities 
are  not  infrequent.  The  muscular  weakness  may  account  for  some  of 
the  spinal  deformities.  A  deep  cavity  at  the  upper  portion  of  the 
chest  in  front  has  been  noted  several  times  by  Astie  ^  and  Schrader  has 
reported  two  cases  presenting  habitual' dislocation  of  the  shoulder  due 
to  changed  contours  of  the  humeral  head  and  the  glenoid  cavity. 

Vasomotor  symptoms  are  represented  by  dermographia,  blueness 
or  redness,  edemata,  and  localized  disturbance  of  perspiration,  especially 
in  the  affected  areas. 

Unusual  Sym.ptoms. — In  various  rare  instances  the  following 
unusual  and  rather  accidental  conditions  have  been  present,  due  to  the 
special  location  of  the  gliomatous  disease  in  the  particular  case  :  Loss 
of  sphincter  control,  sexual  impotence,  suppression  of  menstruation, 
pupillary  inequality,  narrowing  of  the  palpebral  fissure  and  retraction 
of  the  eyeball,  nystagmus,  facial  paralysis,  hypoglossal  paralysis,  optic 
neuritis,  pneumogastric  accidents,  and  bulbar  invasion,  producing  a  pro- 
gressive bulbar  palsy  and  other  cranial-nerve  disablements. 

Course. — Syringomyelia  is  a  chronic  malady  of  slow  progression 
and  fatal  termination.     It  often  presents  stationary  periods 


Fig.  151.— Hands  and  foot  in  cases  of  syringomyelia  of  Morvan's  type,  showing,  1,  mutilations  of  the 
fingers  from  wliitlows,  2,  osteo-artliropalhy  of  wrist-joint,  and  3,  loss  of  toes. 

or  even  slight  temporary  improvement  may  be  noticed.  Bulbar  invasion 
means  early  termination.  It  has  exceeded  forty  years'  duration  iu 
favorable  cases,  and  may  be  interrupted  by  death  from  concurrent  or 
accidental  disease.  Its  logical  termination  is  in  death  by  exhaustion  or 
by  bulbar  crises.  Ulcerations,  dystrophic  conditions,  or  infections  from 
such  sources  may  induce  a  fatal  termination. 

Clinical  Forms. — The  ordinary  form  has  been  in  view  in  the  pre- 
ceding lines.  One  clinical  variety  is  furnished  by  Morvan's  disease.  In 
this  form  the  sensory  dissociation  is  marked,  especially  in  the  hands  and 
arms,  with  associated  atrophy  and  paresis.  There  are  mutilations  of 
the  fingers  by  successive  whitlows  and  marked  cutaneous  dystrophy. 
Scoliosis  and  arthropathies  are  usually  present.  Zambaco  insists  that 
this  is  a  form  of  leprosy,  and  Prus^  has  demonstrated  in  such  a  case  a 
bacillus  closely  resembling  that  of  leprosy.  On  the  other  hand,  Joffroy 
and  Achard  have  demonstrated  central  cord-cavities  in  Morvan's  dis- 
ease, and  this  is  confirmed  by  Thomas.  ^      In  both  a  peripheral  neuritis 

1  "Thfese  de  Paris,"  1897.  ^  "Archiv  f.  Psychiatrie,"  Bd.  xxvii. 

'  "  Rev.  Med.  de  la  Suisse  Romande." 


388 


DISEASES  OF  THE   CORD  PROPER. 


is  common,  and  Prus  suggests  that  the  propagation  of  the  leprous 
bacilli  in  the  cord  might  furnish  the  irritation  that  incites  the  gliomatosis. 
The  question  remains  open. 

There  is  more  than  an  accidental  relation  between  syringomyelia 
and  a  cervical  hypertroj^hio  j^ciehymeningitis.  Brissaud^  insists  that  the 
meningeal  process  usually  precedes  and  furnishes  the  irritation  that  sets 
up  the  central  gliomatosis.  It  seems  probable  that  any  permanent  cord 
irritation  may  lead  to  a  secondary  syringomyelia. 

Prognosis. — The  outlook  in  any  given  case  is  ultimately  fatal,  but 
the  duration  of  the  disease  must  be  estimated  by  the  course  it  is  running 
and  the  portions  of  the  cord  affected.     Bulbar  symptoms  are  extremely 

grave  and  lumbar  involvement  is 
hardly  less  so.  The  tendency  to 
stationary  periods  and  slight  remis- 
sion must,  however,  be  kept  in  mind. 
Diagnosis. — The  diagnosis  de- 
pends upon  the  insidious  develop- 
ment of  the  disease  and  upon  the 
combination  of  sensory,  trophic,  and 
motor  disorders.  The  dissociation 
of  touch  and  pain  is  well-nigh  dis- 
tinctive, but  is  occasionally  found 
in  tabes,  neuritis,  and  hysteria. 
Usually  it  will  be  necessary  to  ex- 
clude progressive  muscular  atrophy, 
amyotrophic  lateral  sclerosis,  pachy- 
meningitis hypertrophica  cervicalis, 
locomotor  ataxia,  and  peripheral  neu- 
ritis. Perhaps  acromegalia,  sclero- 
derma, leprosy,  and  hysteria  may  at 
times  confuse,  but  in  all  these  an 
attentive  study  of  the  combinations 
of  symptoms  should  enable  a  diag- 
nosis to  be  made. 

Treatment  has  proved  futile, 
or  nearly  so.  Measures  looking  to 
the  general  well-being  of  the  patient 
are  most  advisable.  Locally,  massage  and  electricity  may  give  slight 
help  at  times.  Counterirritation  over  the  spine  must  be  used  with 
caution,  as  it  is  capable  of  producing  extensive  and  rebellious  ulcera- 
tion. Surgical  measures  are  likewise  contraindicated  because  of  the 
dystrophic  element  in  the  affected  parts. 


Fig.  152. — Scoliosis  in  Morvan's  type  of 
syringomyelia  (from  a  photograph).  The  spin- 
ous processes  were  marked  with  iodin. 


PROGRESSIVE  MUSCULAR  ATROPHIES  PRESENTING  LESIONS  OF 
THE  SPINAL  GRAY  MATTER. 

All  progressive  muscular  atrophies  may  be  divided  into  those  in 
which  (1)  lesions  of  the  spinal  gray  matter  are  found,  and  (2)  those  in 

^  "  Legons  sur  les  Maladies  Nerveuses, "  1895. 


LESIONS  AND  DISEASES  OF  SPINAL   GRAY.  389 

which  no  such  changes  are  discoverable  by  our  present  means  of  investi- 
gation. It  mav  at  once  be  admitted  tliat  this  division  is  arljitrarv  and 
probably  temporary.  It  is  not  unlikely  tliat  many  members  of  the 
second  group  will  eventually  be  found  in  the  first.  The  present  con- 
ception of  the  integral  character  of  the  lower  motor  neuron,  embracing 
the  spinal  pyramidal  cell,  its  peripheral  prolongation,  and  the  muscular 
organ  under  its  motor  and  trophic  domain,  is  inconsistent  with  the  idea 
that  the  so-called  muscular  dystrophies  or  idiopathic  muscular  atrophies 
are  independent  of  disturbance  in  the  spinal  gray.  For  purposes  of 
convenience  they  will  be  separately  described,  though  every  gradation 
is  found  from  first  to  last,  and  even  a  single  case  may  present  several 
of  the  varieties  at  one  or  in  successive  periods. 

Duchenne,  followed  closely  by  Aran,  in  1849  and  1850  described 
a  progressive  muscular  wasting  without  sensory  disturbance,  which  they 
called  progressive  muscular  atrophy  and  thought  it  a  disease  of  the 
muscles.  Cruveilhier,  in  1855,  recognized  it  as  a  spinal  disease,  and 
Lockhart  Clarke  first  limited  the  lesion  to  the  anterior  spinal  gray 
matter.  Charcot  still  further  differentiated  the  lesion  and  pointed  out 
its  dependence  upon  degeneration  of  the  ganglion-cells  of  the  anterior 
horn.  Later  on  Charcot  distinguished  a  variety  of  progressive  mus- 
cular atrophy  in  which  the  lateral  tracts  were  also  degenerated,  and 
called  it  amyotrophic  lateral  sclerosis.  The  first  variety  is  now  called  by 
French  writers  Duchenne- Aran's  disease,  the  second,  Charcots  disease. 
Of  late,  some  writers,  notably  Marie,  have  tended  to  deny  the  existence 
of  the  Duchenne-Aran  type  in  toto.  Others,  as  Gowers,  insist  that  both 
the  Duchenne-Aran  type  and  the  type  of  Charcot  are  identical,  onlj 
varying  as  the  lateral  tracts  or  the  anterior  gray — that  is,  as  the  upper 
or  lower  motor  neurons — are  first  or  most  degenerated.  Gowers  states 
that  he  has  never  seen  a  case  in  which  lesions  in  both  spinal  regions 
could  not  be  detected,  and  cases  presenting  lesions  confined  absolutely  to 
the  anterior  gray  no  longer  appear  in  current  literature.  ^Nlany  cases 
formerly  classed  with  the  Duchenne-Aran  type  were  doubtless  those 
of  multiple  neuritis,  syringomyelia,  Charcot's  disease,  and  the  so-called 
idiopathic  muscular  atro})hies  to  be  later  described.  AVe  may,  therefore, 
properly  discard  many  of  these  conflicting  terms  and  speak  of  progres- 
sive muscular  atrophy  with  or  without  cord-lesions. 

Attention  is  now  directed  to  the  first  sort,  which  embraces  conditions 
variously  called  spincd  progressive  muscular  atrophy,  ivasting  palsy, 
chronic  poliomyelitis,  amyotrophic  lateral  sclerosis,  cdrophia  muscularis 
progressiva  spinalis,  Duchenne' s  disease,  and  Charcot's  disease. 

Btiolog-y. — Progressive  spinal  muscular  atrophy  is  practically  a  dis- 
ease of  adult  life  occurring  between  the  ages  of  twenty-five  and  fifty,  but 
it  may  appear  earlier  or  later.  It  is  somewhat  more  frequent  in  men  than 
in  icomen.  Direct  inheritance  is  very  rare,  but  a  neuropathic  tendency 
can  occasionally  be  traced.  It  has  been  noted  as  following  various 
alleged  vague  causes,  such  as  anxiety,  overwork,  exposure  to  cold,  con- 
cussion of  the  spine,  syphilis,  and  various  infectious  and  septicemic  states. 
Its  appearance  years  after  an  ctcute poliontyelifishas  been  already  indicated 
under  that  caption.     A  close  inquiry  will  sometimes  detect  a  history  of 


390 


DISEASES  OF  THE  COED  PROPER. 


symptoms  antedating  the  alleged  cause.  There  can  be  little  doubt  that 
at  least  in  some  instances  it  is  an  expression  of  teratological  defect  in  the 
motor  and  trophic  portions  of  the  central  apparatus,  and  constitutes  a 
primordial  shortcoming  by  wliich  these  parts  I'each  an  early  death. 

Morbid  Anatomy. — The  lesions  of  progressive  spinal  muscular 
atrophy  embrace  in  rare  cases  the  entire  motor  field  of  the  nervous 
apparatus  from  cerebral  cortex  to  muscular  nerve-endings,  and  include 
the  muscles  themselves.  Both  upper  and  lower  motor  neurons  in  their 
entirety  are  destroyed  by  a  degenerative  process.  Following  the  patholog- 
ical rule  that  a  neuron  degenerating  from  toxic  cause  or  involution  first 
shows  changes  in  its  peripheral  portion,  the  upper  motor  segment  may 
present  alteration  only  in  the  pyramidal  fibers  of  the  cord.  This  may 
reach  the  medulla,  and,  as  a  rule,  does  not  extend  into  the  peduncles, 
capsule,  and  cortex,  though  it  may  do  so.  In  the  lower  neuron  the  de- 
generation is  probably  at  first  peripheral,  but  in  all  cases  that  reach  a 
marked  development  the  cells  of  the  anterior  gray  are  found  degener- 


Fig.  153.— 1,  Normal  autei-ior  horn;  2,  anterior  horn  in  a  case  of  amyotrophic  lateral  sclerosLs  (Marie). 


ated.  Attending  this  we  have  muscular  atrophy,  with  fibroid  and  fatty 
changes  and  degeneration  in  the  motor  fibers  of  the  nerve-trunks,  limited 
sharply  by  the  anatomical  relations  of  the  diseased  cord-elements. 

In  the  cord  the  gray  substance  of  the  anterior  horns  shows  atrophy. 
The  ganglion-cells,  many  of  which  usually  have  disappeared,  are  wasted 
and  degenerate,  and  there  is  a  general  shrinking  of  all  the  nervous  ele- 
ments of  the  horn.  The  ivhite  substance  of  both  the  direct  and  crossed 
pyramidal  tracts  shows  sclerotic  degeneration.  This  process  is  not 
strictly  confined  to  them,  but  usually  involves  the  anterolateral  tracts  to 
a  lesser  degree,  and  may  invade  the  lateral  limiting  layer.  This  is  espe- 
cially the  case  in  the  upper  dorsal  and  cervical  regions.  The  columns 
of  Goll  sometimes  show  slight  changes,  apparently  due  to  the  shrinking 
of  the  myelin,  and  not  to  an  active  degeneration.  The  lesions  of  the 
anterior  cornua  are  generally  most  pronounced  above  the  dorsal  region, 
l)ut  the  involvement  of  the  crossed  pyramidal  tracts  extends  to  the  lowest 
cord-levels.     Similar  changes  may  be  traced  through  the  medulla,  both 


LESIONS  AND  DISEASES   OF  SPINAL    GRAY. 


391 


in  the  gray  matter  below  the  fourth  ventricle  and  in  the  pyramidal 
tracts  above  the  decussations.  These  latter  may  mount  through  thfe- 
peduncles  and  internal  cajisules  to  the  pyramidal-cell  layers  of  the  cortex, 
and  there  a  cellular  degeneration,  identical  with  that  in  the  spinal  gray, 
may  occasionally  be  encountered. 

The  muscles  are  pale  and  fatty,  and  under  the  microscope  present 
various  changes.  The  fibers  may  be  narrowed,  with  striae  poorly 
marked  or  less  frequent  than  in  health,  or  more  frequent  and  deeply 
marked,  showing  a  tendency  to  fissuration.  The  striation  may  entirely 
disappear  in  fatty  granulations,  and  distinct  globules  or  the  empty  sar- 
colemma  sheaths  may  alone  remain.  Longitudinal  striation  sometimes 
develops,  and    the   transverse   markings    may  later  disappear.       The 


Fig.  154.— Cord-sections  in  a  case  of  amyotropliic  lateral  sclerosis.    1,  Lumbar  region  ;  2,  dorsal  region; 

3,  cervical  region  (Marie). 


nerve-t7'unhs  often  contain  degenerated  fibers,  which  can  be  traced 
through  the  anterior  spinal  roots  to  the  anterior  horns.  All  these  cen- 
tral and  peripheral  changes  vary  in  degree  in  different  cases,  and  inter- 
mediate instances  are  becoming  more  and  more  frequently  noted  in 
which  the  muscles  or  the  nerve-endings  or  the  anterior  cornual  cells 
show  preponderating  changes.  Only  the  most  approved  technic  can 
bie  relied  upon  to  determine  minor  abnormalities. 

Symptoms. — The  various  types  of  spinal  muscular  atrophies  and 
the  confusion  that  has  arisen  over  them,  as  well  as  the  symptoms  in 
various  cases,  are  referable  to  the  vertical  extent  of  the  lesions  and 
the  varying  intensity  of  the  process  at  different  levels.  It  must  at 
once  be  evident  that  if  the  degeneration  falls  first  on  the  lower  neuron, 


392  DISEASES  OF  THE   COED  PROPER. 

flaccid,  atonic,  atrophic  paralysis  will  appear  in  the  periphery.  On  the 
other  hand,  if  the  uj^per  neuron  be  primarily  affected,  the  paralytic 
state  will  Ije  spastic  and  the  tonic  atrophy  will  be  marked  by  rigidities. 
All  degrees  bet\\-een  these  extremes  are  encountered  in  practice.  Flac- 
cidity  may  be  present  in  the  upper  and  spasticity  in  the  lower  extrem- 
ities in  the  same  case.  Involvement  of  the  upper  neuron  can  only  be 
evidenced  through  the  lower  in  the  way  of  increased  reflexes  and  spas- 
ticity. If,  then,  the  lower  neuron  leads  the  upper  in  the  degenerative 
course,  the  latter  can  not  produce  its  signs.  Again,  the  degenerative 
process  falls  by  preference  on  the  cervical  cord  and  manifests  itself  in 
the  upper  extremities  first.  Thence  it  tends  to  extend,  and  eventually 
reaches  the  cranial  nuclei  in  the  bulb,  inducing  a  progressive  bulbar 
palsy.  In  other  cases  the  higher  levels  are  first  affected,  presenting 
bulbar  palsy  or  ophthalmoplegias,  and  the  downward  extension  of  the 
disease  may  be  cut  short  at  any  point  by  pneumogastric  accidents. 
Labiolinguopharyngeal  paralysis  or  bulbar  palsy  is  apparently  identically 
the  same  disease  first  aff'ecting  the  bulbar  centers.  It  is  also  variously- 
combined  with  the  spinal  forms. 


Fig.  15o.— Hand  in  advanced  case  of  amTotrophic  lateral  sclerosis,  showing  muscular  wasting  and  the 
characteristic  ape  position  of  thumb. 

The  muscular  atrophy  and  ireakness  usually  come  on  together  and 
progress  equally.  In  the  great  majority  of  cases  wasting  appears  first 
in  the  radial  half  of  the  hands,  sometimes  first  in  one  hand,  sometimes 
in  both  hands  at  once.  In  another  grouj)  of  cases  the  shoulder-muscles 
are  first  affected.  In  the  hands  the  disease  ordinarily  affects  first 
the  thenar  muscles.  It,  therefore,  appears  to  elect  those  muscles  which 
show  the  highest  differentiation  of  function  and  which  represent  the 
latest  motor  acquirements  in  the  evolutionary  scale, — namely,  circum- 
duction of  the  upper  limb  and  the  opposition  of  the  thumb  to  the 
fingers.  If  the  morbid  process  be  one  of  involution,  we  might  naturally 
expect  such  a  program.  It  results  in  flattening  the  palm,  and  the 
thumV)  falls  back  into  the  same  plane  with  the  other  digits,  producing 
the  -'ape  hand"  (Fig.  155).      The   interossei  and  lumbricales  are  also 


LESIONS  AND  DISEASES  OF  SPINAL   GRAY. 


393 


affected,  and  again  most  on  the  radial  side  of  the  hand.  Fnrrows 
between  the  metaearpals  mark  the  loss  of  the  small  muscles,  and  the 
integument  hangs  loose  and  redundant  with  numerous  folds  and 
wrinkles  over  the  bones,  entirely  denuded  of  muscular  covering  in 
severe  cases.  A  persistence  of  subcutaneous  fat  sometimes  obscuTes 
the  muscular  atrophy.  In  late  cases  there  is  a  marked  tendency  to 
clawing  of  the  fingers,  from  the  involvement  of  the  small  muscles,  so 
that  the  first  phalanges  are  extended,  tlie  second  and  third  sharply 
flexed  (Fig.  155).      They  may  be  rigidly  and  spastically  fixed,  all  vol- 


:  ^ 


Fig.  156. — A  case  of  progressiTe  muscular  atrophy  of  the  spinal  type  in  the  sixth  year  of  the 
disease.    All  skeletal  muscles  affected. 


untary  motion  destroyed,  and  passive  motion  much  limited.  The  mus- 
cles of  the  forearm  suffer  next,  or  they  may  escape  for  a  time  and  the 
shoulder-muscles  waste  first.  In  other  cases  the  muscles  of  the  neck 
are  first  involved,  and  then  those  of  the  upper  extremity,  or  the  wasting 
may  even  develop  first  in  tlie  legs.  Muscles  like  the  pectoralis,  deltoid, 
and  trapezius,  which  have  different  associations,  and  receive  their  inner- 
vation from  different  spinal  levels,  may  waste  in  corresponding  portions. 
It  thus  happens  that  the  upper  portion  of  the  trapezius  is  frequently 
spared  until  late  in  the  disease,  as  it  is  controlled  by  the  spinal  acces- 
sory. Again,  it  may  suffer  early.  The  muscles  of  the  back  are  among 
those  early  invaded,  and  those  of  the  scapula  are  commonly  first 
affected,  allowing  corresponding  displacements  of  this  bone  and  limit- 


394 


DISEASES  OF  THE  COBD  PROPER. 


ing  the  use  of  the  arm.  The  thoracic  muscles  are  also  involved, 
impairing  respiration,  and  if  the  abdominal  groups  suffer,  breathing 
may  become  purely  diaphragmatic.  Wasting  in  the  legs  is  much  less 
common  and  is  usually  less  in  degree,  though  atrophy  may  here  first 
show  itself.  In  the  same  way  the  face  escapes  for  a  time,  or  the  dis- 
ease may  commence  in  the  bulbar  nuclei,  and  labioglossopharyngeal 
palsy  may  be  the  first  step  toward  generalized  progressive  muscular 
atrophy.      Finally,  no  voluntary  muscle  may  escape. 

The  muscular  wasting  and  loss  of  power  result  in  corresponding 
changes  of  contour  and  position  deformities.  The  patient  may  be 
unable  to  hold  the  head  erect.  The  uncovered  acromium  renders  the 
shoulder  angular.     The  claw-hand,  the  scoliotic   spine,  the  displaced 


Figs.  157  and  158. — Hand  in  early  amyotrophic  lateral  sclerosis,  showing  excavation  of  the  interosseous 
spaces  and  flattening  of  palmar  eminences. 

scapula,  and  the  distorted  chest  manifest  the  unsupported  skeleton; 
The  characteristic  of  the  atrophy  is  its  gradual  invasion  of  a  muscle 
fiber  by  fiber,  commonly  preceded  by  fibrillai-y  twitchings.  These 
twitchings  are  sometimes  decidedly  exaggerated,  causing  arhythmic  jerk- 
ing movements  of  the  hands  and  arms  or  twitchings  of  facial  muscles. 

The  reflexes  may  be  either  abolished  or  more  commonly  increased  in 
activity.  Early  and  rapid  wasting  is  often  marked  by  diminution  and 
even  extinction  of  the  reflexes  in  the  aflFected  muscle  ;  but,  again,  there 
is  often  early  rigidity  and  marked  myotatic  irritability,  which  last 
throughout  the  disease  and  persist  even  when  the  muscles  are  much 
wasted,  or  reflexes  at  first  exaggerated  may  disappear.  The  reason  for 
this  variability  has  been  already  indicated. 

In  the  lower  extremities,  however,  it  is  the  rule  that  the  reflexes  are 
augmented  and  spastic  disturbance  of  a  paraplegic  sort  is  commonly 


LESIONS  AND  DISEASES  OF  SPINAL  GRAY.  395 

found  unless  the  atrophy  begins  in  the  lower  members.  This  gives  rise 
to  the  spastic  gait  often  marked  by  clonus  and  dragging  footsteps.  The 
rigidity  may  show  itself  by  the  fixity  of  position,  even  when  the  patient 
is  seated  or  in  bed.  The  legs  tend  to  extension,  the  arms  to  demiflexion, 
and  the  hands  are  held  in  the  negative  position,  midway  between  pro- 
nation and  supination.  The  sphincters  are  seldom  affected.  An  excea- 
sive  jaiv-jerk  can  sometimes  be  elicited,  and  implies  bulbar  extension  of 
the  disease.  The  cutaneous  reflexes  are  normal  so  long  as  their  muscles 
survive  the  atrophic  invasion. 

The  bulbar  symptoms  of  the  disease  correspond  to  those  of  bulbar 
palsy  (see  p.  151).  Fibrillary  twitchings  about  the  mouth  and  eyes 
and  in  the  tongue  are  followed  by  wasting,  and  the  characteristic  facial 
expression  is  developed.  In  advanced  cases  the  open  mouth,  the 
druling  saliva,  the  difficulty  of  deglutition,  the  nasal  voice,  and  the 
pneumogastric  palsies  only  too  plainly  indicate  the  upward  extension  of 
the  disease  and  the  critical  condition  of  the  patient.  The  pharyngeal 
reflex  usually  persists  as  long  as  the  pharyngeal  muscles  have  power  to 
act.     The  mind  is  not  distu-rbed. 

The  electrical  response  in  nerves  and  muscles  is,  as  a  rule,  quantita- 
tively reduced  for  both  currents,  and  finally  extinguished.  In  a  rough 
way  it  is  proportionate  to  the  amount  of  muscular  fiber  present.  In  most 
instances  the  reaction  of  degeneration  is  found  in  a  few  muscles,  or  any 
variation  of  it  may  be  presented. 

Sensibility  is  practically  intact.  In  some  instances  there  is  complaint 
of  dull  pains  at  or  before  the  onset  of  atrophy,  and  vague  feelings  of 
weakness,  fullness,  and  formication  may  be  mentioned  during  the  disease. 
The  paralytic  and  wasted  limbs  are  usually  cold  and  the  circulation  is 
poor,  but  trophic  disturbance  in  the  skin,  perforating  ulcers,  arthrop- 
athies, and  bedsores  are  unknown.  The  visceral  functions  are  not 
notably  impaired. 

Varieties. — The  chief  varieties  to  be  distinguished  are  :  First,  cases 
marked  by  flaccid,  atonic  atrophy,  which  reaches  an  extensive  degree, 
usually  first  appearing  in  the  small  muscles  of  the  hands, — the  Duchenne- 
Aran  type  ;  second,  cases  marked  by  similar  wasting,  but  less  in  degree, 
and  presenting  tonicity,  rigidity,  and  increased  reflexes  from  the  first, — 
amyotrophic  lateral  sclerosis,  or  Charcot's  disease  ;  third,  an  intermediate 
variety  with  only  slight  muscular  wasting,  but  with  great  weakness  and 
with  spasms  and  retained  reflexes ;  fourth,  the  variety  beginning  as  a 
labioglossopharyngeal  paralysis,  an  ophthalmoplegia,  or  some  bulbar  palsy. 

Course. — These  spinal  muscular  atrophies  may  commence  in 
various  ways  and  first  invade  any  portion  of  the  cord  or  the  bulb. 
The  clinical  course  varies  accordingly.  It  is,  however,  progressive, 
and  may  terminate  in  a  few  months  or  a  year,  or  consume  twenty  or 
thirty  years  in  its  evolution.  Apparently  stationary  periods  in  the 
protracted  cases  are  not  uncommon,  but  the  logical  termination  in  all  is 
death  from  cardiac  or  respiratory  failure.  Intercurrent  disease,  espe- 
cially acute  infections  and  particularly  pneumonia,  are  badly  borne  and 
frequently  end  life. 

Diagnosis. — In   fully  developed  cases   of  the    spinal    progressive 


396  DISEASES  OF  THE  COED  PROPER. 

atrophies  the  diagnosis  is  usually  not  difficult,  but  a  differentiation  from 
the  so-called  idiopathic  muscular  atrophies  of  the  next  section  may 
sometimes  be  impossible.  AVe  rely  upon  the  presence  of  fibrillary 
twitching,  increased  reflexes,  if  only  in  the  legs,  and  the  reaction  of 
degeneration  in  at  least  some  of  the  muscles,  to  indicate  the  spinal 
location  of  gross  changes.  These  cases  usually  begin  in  adult  life  and 
show  no  particular  family  history  ;  the  second  group  usually  begin  in 
childhood  and  are  frequently  familial.  The  spinal  yarieties  select  the 
muscles  of  the  hands,  shoulders,  or  lips  first ;  the  idiopathic  yarieties 
commonly  spare  the  hands  at  first  and  may  select  the  humeral  muscles 
or  the  peroneal  group  first,  and  are  frequently  marked  by  pseudohyper- 
trophies,  especially  of  the  calf,  gluteal,  and  scapular  muscles.  Jlulti- 
pjle  neuritis  ordinarily  affects  all  four  extremities  and  can  be  traced  to 
some  competent  infection  or  poisoning.  In  it  the  sensory  symptoms  are 
prominent  from  the  first,  while  they  are  slight  or  absent  in  spinal 
myopathies.  Syringomyelia  may  produce  a  local  atroj)hy,  but  has  its 
distinctiye  index  in  the  dissociation  of  cutaneous  sensations  and  the 
usual  presence  of  arthropathies  and  other  trophic  disorders,  besides 
usually  being  unsymmetrical.  JIultiple  arthritis  is  sometimes  marked 
by  extreme  muscular  atrophy.  Here  we  haye  the  early  history  of 
articular  disease  and  the  continued  existence  of  arthritic  mischief. 
The  wasting,  too,  is  usually  on  the  proximal  side  of  the  joints,  thus 
sparing  the  small  muscles  of  the  fingers.  It  is  as  likely  to  appear  in 
the  lower  as  the  upper  extremities,  is  rarely  accurately  bilateral,  and 
affects  first  and  principally  the  joint  extensors.  The  reflexes  may  be 
increased,  if  not  inhibited  by  pain  or  ankylosis,  and  the  faradic 
irritability  is  usually  increased.  Transverse  myelitis  is  limited  distinctly 
by  an  upper  border  of  sensory  and  anatomically  corresponding  motor 
disturbance.      The  onset  and  clinical  history  are  acute. 

Prog-nosis. — The  prognosis  is  always  graye,  and  in  proportion  as 
the  disease  tends  to  inyade  the  bulb  death  is  imminent.  Intercurrent 
affections  present  more  than  their  proper  danger. 

Treatment  is  practically  futile,  but  should  none  the  less  be  consci- 
entiously instituted.  The  application  of  the  thermocautery  to  the  back, 
the  careful  use  of  exercises,  massage,  and  electricity  to  the  muscles,  and 
endless  attention  to  the  general  health  and  the  processes  of  nutrition  and 
elimination  may  prolong  life.  The  danger  of  choking  to  death  or  of 
inducing  an  aspiration  pneumonia  when  the  pharynx  is  inyolyed  must 
be  borne  in  mind.  It  is  to  be  hoped  that  some  product,  perhaps  of 
biochemistry,  may  be  discoyered  that  will  maintain  yitality  in  the  de- 
generating motor  apparatus  and  postjjone  the  inyolutional  changes  of 
the  disease. 

PROGRESSIVE  MUSCULAR  ATROPHIES  NOT  MARKED  BY  STRKING 
HISTOLOGICAL  CORD-LESIONS. 

The  yiew-point  regarding  a  group  of  clinical  forms  that  haye  in 
common  the  feature  of  progressiye  muscular  weakness  and  atrophy, 
often  associated  with  hypertrophy  or  pseudohypertrophy  of  some  mus- 
cles, has   altered   markedly  during  the   past   few^  years.     When  it  was 


LESIONS  AND  DISEASES  OF  SPINAL   GRAY.  397 

first  found  that  such  cases  presented  no  spinal  lesion,  they  were  termed 
p7'ogressive  muscular  dydropkies  by  Erb,  and  'primitive  jyrogreasive  myopa- 
thies by  Charcot.  A  variety  of  forms  were  described  by  different 
observers,  whose  names,  unfortunately,  became  associated  with  and 
served  to  fix  these  variations,  which  are  now,  following  Erb,  Brissaud, 
Sachs,  and  others,  grouped  under  a  common  head.  Writers  also  refer 
to  the  pseudohypertropkic  form,  the  brachial,  facioscapulohume7-al,  pelvic, 
and  peroneal  types,  as  hypertrophy  prevails  or  the  atrophy  is  most 
pronounced  in  the  various  indicated  regions.  As  material  has  accumu- 
lated, transition  forms  have  been  encountered  with  increasing  fre- 
quency. Two  or  more  of  the  foregoing  types  have  been  found  in 
the  same  patient  or  in  members  of  the  same  family.  What  is 
more  important,  the  same  family  has  presented  cases  of  progressive 
muscular  atrophy  of  the  spinal  form  and  also  of  the  so-called  idiopathic 
muscular  variety  in  one  or  in  succeeding  generations.  Again,  there  is 
an  increasing  number  of  observations  going  to  show  that  in  the  so-called 
myopathic  cases  the  spinal  gray  is  not  absolutely  normal.  A  much 
larger  series  of  observations  discover  changes  in  the  muscle  nerve- 
endings  or  in  the  peripheral  extremities  of  the  lower  neurons.  The 
so-called  peroneal  or  neurotic  type  furnishes  an  intermediate  form 
between  the  spinal  and  the  alleged  purely  muscular  varieties.  This  is 
clinically  indicated  by  the  fibrillar  twitchings,  the  reaction  of  degenera- 
tion, the  relation  of  the  muscular  dystrophy  to  certain  spinal  segments, 
and  the  functional  relation  of  the  affected  muscles.  Yet  similar  seg- 
mental and  functional  outlines  are  presented  by  all  cases.  This  alone 
compels  an  acknowledgment  of  the  spinal  factor.  An  attentive  and 
intelligent  study  of  any  given  case  will  usually  show  the  features  of 
several  of  the  so-called  types  and  serve  to  prove  their  essential  identity. 
The  upper  spinal  levels  or  the  musculature  pertaining  to  the  upper 
spinal  segments  are  first  invaded  in  some ;  in  others,  the  lower  portion 
of  the  cord  first  manifests  the  disease. 

If  any  significance  is  attached  to  the  autonomy  of  the  lower  motor 
and  trophic  neuron,  it  will  be  impossible  to  consider  the  cell-body  in  the 
spinal  horn  as  above  reproach  when  its  axial  prolongation  shows  degen- 
erative changes,  or  when  its  trophic  control  is  perverted  or  destroyed. 
At  present  such  change  in  the  cell  may  be  called  dynamic  or  functional 
when  no  morphological  alteration  can  be  discovered,  but  the  pertinent 
fact  remains  that  actual  changes  appear  in  some  instances,  and  the  prob- 
ability is  strong  that  improved  technic  will  discover  them  in  all. 
Sainton  ^  has  found  well-marked  changes  in  the  spinal  cord  in  the 
neurotic  form,  and  Abadie  and  Denoyes,^  in  a  typical  pseudohyper- 
trophic case,  obtained  the  electrical  reactions  of  degeneration  that 
are  supposed  to  be  a  part  of  spinal  and  nerve  disintegration.  Indeed, 
as  before  insisted,  every  gradation,  from  progressive  spinal  muscular 
atrophy  to  cases  only  showing  muscular  changes,  can  be  adduced. 
Some  observers,  however,  insist  that  the  spinal  changes  are  secondary 
to   the  muscular  atrophy,^  and  well-examined  cases  still  fail,  in  some 

1  ' '  Nouv.  Icon,  de  la  Salpet. , ' '  June,  1899.     ^  ' '  Nouv.  Icon,  de  la  Salpet. , ' '  Aug. ,  1900. 
3  Pick,  "Deutsch.  Zeit.  f.  Nervenh.,"  Bd.  xvii,  1900. 


398  DISEASES  OF  THE  COED  PROPER. 

instances,  to  present  any  demonstrable  cord  variation,  even  when  the 
clinical  type  suggests  the  spinal  variety  of  disease. 

These  muscular  atrojoMes,  to  adopt  that  term  for  convenience  only, 
have  in  common  a  familial  tendency.  They  often  appear  in  several 
members  of  a  given  family  or  in  blood-relations  of  the  same  or  different 
generations.  While  they  may  appear  at  any  age,  they  show  a  marked 
tendency  to  occur  in  the  early  years  of  life,  and  commonly  affect  the 
roots  of  the  extremities  rather  than  their  distal  ends.  They  are  almost 
always  unmarked  by  changes  of  sensibility,  by  fibrillar  twitchings,  and 
by  the  electrical  reactions  of  degeneration. 

Etiology. — Regarding  the  causation  of  these  progressive  myopathic 
atrophies  very  little  can  be  positively  stated.  Their  appearance  in  sev- 
eral members  of  the  same  family  or  in  several  members  of  succeeding 
generations,  their  interchangeability  of  form,  their  propagation  by  the 
females,  their  appearance  during  the  age  of  active  growth  and  at  de- 
velopmental epochs  of  life,  stamp  them  as  hereditary,  familial,  and  em- 
bryonic. Meek  has  demonstrated  that  new-born  animals  possess  many 
more  muscle  fibers  than  adults,  as,  for  instance,  in  the  biceps,  and  Pick  ^ 
suggests  that  in  some  instances  this  natural  disappearance  of  muscle 
fibers  may,  from  prenatal  or  other  cause,  exceed  physiological  limits  and 
produce  progressive  dystrophy.  The  flabby  and  wasted  muscles  of  old 
age  may  be  in  part  due  to  a  similar  cause.  Age. — The  great  majority 
of  cases  appear  before  puberty  is  established,  with  especial  frequency 
during  the  second  dentition  and  at  pubescence.  Others  are  first  mani- 
fest during  adolescence,  from  eighteen  to  twenty-six  years  of  age ;  and 
a  rapidly  diminishing  series  is  encountered  later  in  life.  It  sometimes 
happens  that,  appearing  at  adult  years  in  one  generation,  the  myopathy 
follows  in  early  childhood  in  the  next.  As  males  are  rendered  impo- 
tent by  the  disease,  its  transmission  necessarily  falls  to  those  females 
of  the  family  who  escape  and  reach  maturity.  In  addition,  hoys  seem 
more  frequently  affected  than  girls.  Appearing  commonly  during  the 
years  of  childhood,  it  often  follows  the  diseases  peculiar  to  that  period 
of  life,  but  it  is  difficult  to  assert  their  causative  activity.  In  some 
cases  diphtheria  has  seemed  to  lead  to  it ;  in  others  it  has  followed 
exposures  to  cold,  slight  injuries,  and  infections.  Given  a  neuron 
feebly  endowed  with  enduring  qualities,  it  is  not  improbable  that  any 
condition  capable  of  reducing  the  general  health,  or  any  toxic  state  may 
act  upon  it  with  unusual  virulence. 

Morbid  Anatomy. — The  muscles  show  various  morphological 
changes,  depending  upon  the  presence  of  hypertrophy,  pseudohyper- 
trophy, or  atrophy, — the  final  and  logical  end  for  all  the  affected  muscles. 
The  sarcode  elements  may  be  hypertrophied  or  atrophied.  Enlarged 
fibers  may  be  found  in  a  mass  of  greatly  wasted  muscular  tissue.  There 
is  round-cell  infiltration,  vacuolation,  splitting,  division,  and  longitudi- 
nal striation  of  muscle-fibers,  with  hyperplasia  of  connective  tissue  and 
an  increase  in  fat  that  may  reach  the  highest  degree  of  lipomatosis. 
The  early  changes  consist  of  increase  of  connective  tissue,  possibly 
some  muscular  hypertrophy,  then  muscle  atrophy  and  fatty  infiltration. 

^  Pick,  loc.  cit. 


LESIONS  AND  DISEASES  OF  SPINAL  GRAY. 


399 


What  appears  clinically  as  a  large  muscular  mass,  in  some  instances  is 
found  to  be  a  .markedly  lipomatous  structure  almost  devoid  of  muscular 
fibers. 

Von  Babes  ^  has  found  the  muscle  nerve-plates  undeveloped  and 
degenerated.  Heubncr,  Striimpell,  and  Marinesco  have  described  the 
peripheral  nerves  as  degenerated  in  the  peroneal  or  leg  type  of  the 
disease ;  the  muscles  and  the  anterior  pyramidal  cells  of  the  cord  were 
also  involved.  Hoppe  has  found  similar  changes  in  the  facioscapulohu- 
meral variety.  Sachs  and  Brooks  ^  have  observed  universal  shrinkage 
of  the  posterior  root  ganglion  cells  in  one  case.  To  ordinary  reagents 
the  nerves  and  pyramidal  cells  usually  react  in  a  normal  manner,  but 
the  finer  technic  of  recent  years  is  likely  to  determine  changes  in  both. 


Figs.  159  and  160.— Scapulohumeral  type  oi  progressive  muscular  atrophy.  Note  the  angle  on  right 
side  of  neck  with  lengthening  of  the  neck,  due  to  wasting  of  the  trapezius,  and  the  peculiarity  of  the 
deltoid. 

Symptoms. — The  most  striking  symptoms  depend  upon  the  changes 
of  eontour  in  muscles  and  their  loss  of  strength.  These  are  variously 
combined  in  different  cases.  We  will  first  take  them  up  in  systematic 
order,  and  finally  group  them  in  describing  the  common  types  of  the 
disease.  The  myopathic  fades  depends  upon  the  ^^aresis  of  the  facial 
muscles.  The  face  presents  a  vacuous,  sleepy,  inert  expression,  and 
fails  to  adequately  show  forth  the  lively  emotions  that  may  actuate  the 
patient.  The  brow  is  smooth,  and  the  frontalis  is  unable  to  assist  in 
raising  the  thin  and  drooping  eyelids.  The  wasting  of  the  eyelid  mus- 
cles may  give  the  eyeball  a  false  appearance  of  prominence  and  cause  a 
haggard  expression.  The  lower  lid,  from  the  laxity  of  its  tissues,  often 
^  "La  Semaine  Med.,"  A\ig.,  1894.         ^  "Amer.  Jour.  Med.  Sciences,"  July,  1901. 


400 


DISEASES  OF  THE   CORD   PROPER. 


tends  to  droop.  The  cheeks  and  lips  are  flaccid,  and  the  lower  portion 
of  the  face  droops  from  the  bones.  The  eyes  can  not  be  firmly  closed 
nor  the  lips  puckered.  In  some  cases  the  lips  are  thickened  by  hyper- 
trophy and  drag  down,  increasing  the  nasolabial  furrows.  The  mouth 
may  then  remain  open  constantly,  with  a  thickened,  pendent  lower  lip. 
In  other  cases  the  lips  are  thinned,  motionless,  and  can  not  be  retracted 
from  the  teeth.  In  either  case  puffing,  whistling,  or  spitting  is  poorly 
performed  or  impossible.  The  movements  of  the  eyeballs  are  usually 
not  disturbed,  but  in  two  cases  the  author  has  noted  a  very  great  loss  of 
conjugate  lateral  movements.  Movements  of  the  tongue  may  also  be 
greatly  limited.  The  palatal  excursions  may  likewise  be  reduced  in 
amplitude,  and  laryngeal  disturbance  may  be  added. 


Figs.  161  and  162. — Case  of  facioscapulohumeral  type,  showing  facies,  tapir  mouth,  horizontal 

clavicles,  etc. 


Brissaud  calls  particular  attention  to  an  apparent  lengthening  of  the 
neck  that  he  finds  a  constant  symptom,  and  due  to  tlie  drooping  of  the 
shoulder.  The  direction  of  the  clavicle  is  frequently  outward  and  down- 
ward^ instead  of  upward,  as  in  health.  This  may  be  accentuated  by  the 
early  involvement  of  the  trapezius,  causing  the  characteristic  angle,  as 
shown  in  figures  159  and  160.  The  drooping  shoulder  may  also  appear 
only  on  one  side.  Attempts  to  extend  the  arms  laterally,  or  even  to  hold 
them  rigidly  at  the  sides,  cause  a  widening  of  the  neck  by  the  promi- 
nence of  the  upper  borders  of  the  trapezii.  The  supraclavicular  notches 
are  thereby  inordinately  exaggerated  and  the  sternomastoids  spring  into 
great  prominence.  Even  the  upper  inner  angle  of  the  scapula  may  be- 
come salient  above  the  normally  curved  line  from  mastoid  to  acromion. 
The  scapulce  are  usually  mobile,   and   may  wing  out   freely  from   the 


LESIONS  AND  DISEASES  OF  SPINAL  GEAY.  401 

chest.  The  spinati  muscles,  especially  the  infraspinatus,  has  a  marked 
tendency  to  pseudohypertrophy,  which  may  add  greatly  to  the  scapular 
deformity  and  accentuate  the  anterior  curve  of  the  lumbar  spine  when 
viewed  from  the  side.  This  curvature  is  very  commonly  present,  and 
may  reach  extreme  proportions.  It  is  due  to  the  weakening  of  the  spinal 
erectors  in  part,  but  is  increased  greatly  when  the  glutei  allow  the  pefe/s 
to  tip  forward  on  the  heads  of  the  femurs,  and  is  dragged  into  still 
greater  prominence  by  the  protuberant  belli/,  due  to  the  weakened 
al)dominal  muscles. 

The  deltoid  requires  particular  mention.     It  is  commonly  hypertro- 
phied  and  shows  the  marked  discrepancy  between  the  bellies  and  extreml- 


• 


Fig.  163. — Progressive  luuscular  atrophy  at  advanced  stage,  showing  deformities  about  shoulders,  with 
pseudohypertrophy  of  infra-spiuati,  wasting  of  all  dorsal  muscles,  and  spinal  anterior  curvature. 

ties  often  found  in  long  muscles.  The  fibrous  changes  are  marked  at 
the  origin  of  the  muscle  from  the  scapula  and  clavicle,  apparently  dis- 
placing the  full,  round  shoulder-cap  to  the  outside  of  the  neck  of  the 
humerus,  where  it  stands  out  as  a  lumpy  mass  (see  Figs.  159  to  177). 
Similar  changes  in  coutour  are  occasionally  encountered  in  the  biceps 
of  the  arm,  in  the  anterior  crural,  and  in  the  sural  group.  The  forearms 
and  hands  are  commonly  spared,  at  least  until  very  late  in  the  disease, 
but  K.  Mendel  ^  has  reported  a  case  showing  early  involvement  of  the 
interosseal  muscles  of  the  bauds.  The  glutei  and  the  gastrocnemii 
are  favorite  locations  for  pseudohypertrophy.  The  calf-muscles  also 
are  frequently  shortened  so  that  the  patient  can  not  raise  the  toes 
from  the  floor  while  standing  on  his  heels  nor  can  the  foot  be  passively 
flexed  beyond  a  right  angle.  This  interferes  with  the  gait,  causing 
the  patients  to  stumble  over  the  smallest  obstacles.  It  may  even  pro- 
duce an  equinovarus.  In  rare  cases,  as  in  the  one  illustrated  on  page 
402,  a  general  increase  in  the  adipose  tissue  may  greatly  obscure  the 
underlying  muscular  defects  and  maintain  a  fictitious  appearance  of 
muscular  development  that  is  belied  by  great  weakness.  In  the  same 
way  the  muscles  presenting  pseudohypertrophy  look  immensely  strong, 

1  "Neurol.  Centralbl.,"  July  1,  1901. 
26 


402 


DISEASES  OF   THE   CORD  PROPER. 


and  feel  very  firm,  but  are  found  lacking  in  contractile  power  and  sub- 
ject to  fibroid  shortening. 


Figs.  164  and  165. — Progressive  amyotrophy  masked  by  fat 
except  in  legs  and  face. 


Fig.   166.— Showiii.  .d 

in  advanced  iuy<ipatDy. 


Figs.  167,  168,  and  169.— Waddling  gait  in  a  case  of  pseudohypertrophic  paralysis. 

The  attitude  presented  by  the  patients  is  the  result  of  the  atrophic 
and  paretic  condition  of  the  affected  muscles  and  of  the  contractures 
that  sometimes  appear  in  them.      It,  therefore,  varies  with  the  location 


LESIONS  AND   DISEASES   OF  SPINAL    GEAY.  403 

of  the  disease.  Owinu-  to  the  sliortcninu-  of  the  calf  muscles,  little  diffi- 
culty is  found  in  maintaining  the  ankle-joint  at  a  proper  angle  unless  an. 
equine  position  of  the  f(^ot  has  developed,  causing  the  patients  to  stand 
u[)()n  their  toes.  Standing  then  becomes  extremely  difficult.  The  posi- 
tion at  the  knee  and  hip  is  often  entirely  dependent  upon  the  ligament- 
ous support  of  these  joints.  This  allows  the  pelvis  to  tip  forward  upon 
the  head  of  the  femurs  and  necessitates  a  strong  anterior  spinal  bend 
to  carrv  the  head  and  shoulders  back  into  the  line  of  gravity  for  the 
maintenance  of  the  equilibrium.  The  prominence  of  the  abdomen  is 
thus  produced  and  is  accentuated  in  turn  by  the  weakness  of  the  abdomi- 
nal muscles.  In  some  cases  the  head  is  tilted  backward,  but  when  the 
spinal  curve  is  pronounced  the  chin  may  rest  on  the  sternum.  Ordi- 
narily the  feet  are  kept  wide  apart  to  increase  the  base  of  support. 

The  gait  is  broad-based  and  waddling  (Figs.  167,  168,  and  169).  The 
foot  to  be  advanced  is  clumsily  put  forward,  the  pelvis  tilting  sharply 
downward  on  that  side,  the  body  being  inclined  over  the  supporting 
foot  as  a  counterpoise  to  the  swinging  liml).  This  is  repeated  in  the 
opposite  sense  at  the  next  step,  and  the  patient  advances  in  a  swaying, 
waddling,  awkward  fashion,  stumbling  over  the  least  obstacle,  and  falling 
heavilv  if  the  very  unstable  equilibrium  is  momentarily  lost.  Mounting 
stairs  is  often  an  early  difficulty. 

The  manner  of  rising  from  the  ground  is  most  characteristic.  If 
placed  on  the  back,  the  patient  may  have  great  difficulty  in  rising  at  all. 
His  usual  plan  is  to  turn  over  on  his  face,  then  huddle  himself  together, 
and  get  upon  his  knees.  The  usually  weakened  psoas,  vastus,  and 
gluteal  muscles  are  now  inadec|uate  to  the  effort  of  lifting  him.  He, 
therefore,  advances  the  body  into  the  "  all  fours  "  position,  and,  carrying 
the  weight  of  the  head  and  shoulders  on  the  arms,  pushes  up  the  lower 
end  of  the  trunk  with  his  legs  as  a  cow  gets  up  by  the  hindquarters. 
The  hands  are  now  brought  toward  the  feet,  one  is  placed  above  the 
knee  on  the  same  side,  then  the  other  at  a  higher  point  on  the  thigh  of 
its  own  side ;  the  shoulders  and  head  are  pushed  upward,  the  pelvis  tilts 
forward,  the  sway-back  suddenly  appears,  and  the  patient  attains  the 
erect  attitude  by  a  process  of  climbing  up  his  own  legs  (Figs.  170  to 
175).     In  late  stages  standing  and  walking  may  be  impossible. 

It  is  needless  to  say  that  in  the  cases  in  which  the  legs  and  pelvic 
muscles  escape  or  are  only  slightly  affected,  the  attitude,  gait,  and  man- 
ner of  rising  are  not  disturbed.  The  sway-back  may  also  disappear 
when  the  patient  is  sitting,  or  may  then  give  place  to  a  rounding  of  the 
back,  the  patient  resting  his  elbows  on  his  knees  or  otherwise  gaining 
a  fictitious  support  for  the  upper  j^art  of  the  trunk. 

The  upper  extremity  is  most  affected  by  the  impairment  of  the  mus- 
cles of  the  shoulder-girdle.  Xext  in  frequency  the  brachial  group  is 
affected,  while  the  muscles  of  the  forearm  aud  hand  are  usually  spared. 
In  the  lower  extremity  wasting  rarely  avoids  the  gluteal  and  psoas  groups 
and  commonly  affects  the  anterior  crural  distribution.  The  calf-mus- 
cles with  the  glutei  furnish  favorite  locations  for  pseudohypertrophy, 
while  the  calf-muscles  in  addition  are  the  commonest  of  all  locations 
for  fibroid  contractures,  which  may,  however,  appear  in  any  muscle  in 


404 


DISEASES  OF  THE   CORD   PROPER. 


the  late  stages  of  atrophic  shrinking.      The  small  muscles  of  the  foot 
may  escape.     The  peronei  are  selected  first  in  the  leg  type. 

The    tendon-reflexes  are  usually   diminished,    and   when  wasting  or 


Figs.  170,  171,  and  172. — Method  of  rising  from  the  ground  in  cases  of  myoijathy. 


Figs.  173,  174,  and  175.— Method  of  rising  from  the  ground  in  myopathy. 


pseudohypertrophy  is  apparent  they  are  commonly  abolished.  The  or- 
dinary case  shows  only  a  quantitative  reduction  of  electrical  muscular 
stimidatahility  for  both  currents.  In  rare  instances,  and  usually  in  the 
peroneal  or  so-called  neurotic  type,  the  reaction  of  degeneration  may  be 


LESIONS  AND   DISEASES  OF  SPINAL   GRAY. 


405 


obtained.  Fibrillary  twitchings  and  severe  pains  are  equally  rare,  but 
are  found  under  similar  circumstances.  The  sphinciers  are  not  affected. 
Sensation  is  intact  in  all  its  modes  and  tenses.  A  large  ])roportion  of 
these  cases,  and  perhaps  all  of  them  dating  from  early  childhood,  show 
some  mental  bachvardness  and  apathy.  Trophic  disturbances  are  not  en- 
countered, hut  c/roicth  may  be  retarded  and  the  bones  may  be  diminutive.  ^ 
Course. — These  conditions  are  i^rogressive.  The  muscular  wasting 
usually  steadily  advances  with  its  attendant  and  increasing  weakness. 
Some  cases  present  stationary  periods  without  assignable  cause,  and 
resume  their  course  without  adequate  explanation.  As  a  rule,  the 
younger  the  age  at  which  the  disease  appears,  the  more  rapidly  does  it 
incapacitate   the   individual.      It  commonly  occurs   in   girls  at  a   later 


^ 


Fig.  176. — Showing  attitude,  fades,  deltoid,  and 
calf  deformities  in  a  case  of  pseudoiiypertropbic 
paralysis. 


Fig.  177. — Advanced  case  of  progressive  my- 
opathy, at  one  time  marked  by  pseudohypertro- 
phies.  Observe  facies,  deltoid  conformation,  and 
comparative  integrity  of  hand  and  forearm. 


period  than  in  boys,  and  then  runs  a  slower  course.  When  commenc- 
ing in  childhood,  sometimes  an  age  of  forty  years  may  be  reached,  but 
death  usually  occurs  between  twenty  and  thirty.  Not,  as  a  rule,  fatal  in 
itself,  except  by  pneumogastric  accidents,  death  ordinarily  occurs  from 
intercurrent  disease. 

Varieties. — A  number  of  clinical  varieties  have  been  described 
and  are  worthy  of  some  attention,  but  it  should  be  borne  in  mind  that 
they  are  not  distinct  morbid  conditions. 

The  earliest  recognized  form  is   the  one  called   jpseudohyperh'ophie 

paralysis.     It  usually  appears    in  early  childhood,  affects  boys   much 

more  frequently  than   girls,   and    is  marked  by  extreme    enlargement 

of  the  calves  and  buttocks.     These  stand  out  in  intensified  relief  next 

1  Schultze,  "Deutsch.  Zeit.  f.  Nervenh.,"  April,  1899. 


406 


DISEASES  OF  THE  CORD  PROPER. 


the  wasted  thighs  and  forward-tilted  pelvis.  The  psoas  group  is  early 
aifected,  rendering  going  up-stairs  difficult  at  an  early  date.  False 
hypertrophy  is  also  commonly  found  on  the  dorsum  of  the  scapula,  in 
the  lower  border  of  the  pectoralis,  and  the  lower  part  of  the  deltoids. 
The  serratus  magnus,  erector  spinse,  and  humeral  muscles  commonly 
suifer  early.  The  myopathic  facies  is  not  well  marked,  but  can  be 
detected  in  late  cases.  The  forearms,  hands,  and  feet  are  commonly 
spared  until  the  last.  The  enlarged  muscles  finally  shrink,  and  present 
all  the  features  of  those  that  shrink  from  the  first. 


Fig.  178. — A  mixed  case  showing  faoioscapulohuuieral  iuvoivemeut,  peroneal  wasting,  and  the  foot 
deformity  of  Friedreich's  disease.  There  were  fibrillary  twitchings  and  the  reaction  of  degeneration 
in  the  leg  muscles. 


The  j^eroneal  or  leg  variety,  sometimes  called  the  Charcot-Marie  type, 
or  the  neurotic  form,  is  marked  by  the  early  atrophic  shrinking  of  the 
peroneal  muscles.  The  calves  are  next  involved  and  the  thighs  follow. 
The  disease  may  thus  be  confined  to  the  lower  extremities  for  years. 
Eventually  it  invades  the  trunk  and  upper  extremities,  fi.rst  affecting 
the  hands.  It  shows  fibrillar  twitchings,  the  electrical  changes  of 
degeneration,  and  presents  undoubted  cord-lesions. 

The  juvenile  type  of  Erh,  also  called  the  brachial  form,  affects  mainly 
the  muscles  of  the  arms  and  shoulders,  and  appears  in  early  youth,  and 
usually  in  several  members  of  the  same  family. 

The  facioscapulohumeral  form,  or  the  tyjje  of  Landouzy-Dejerine, 
affects   face,  shoulder,  and  arm,  or  may  be  considered  as  the  brachial 


LESIONS  AND  DISEASES  OF  SPINAL  GRAY.  407 

form  plus  facial  involvement.  These  cases  furnish  marked  instances 
of  the  myopathic  facies. 

Several  of  these  forms  may  be  present  in  the  same  patient,  as  the 
leg  type  with  the  facioscapulohumeral  variety,  or  pseudohypertrophy 
in  the  legs  and  the  brachial  type  above.  The  hypertrophic  variety 
regularly  becomes  shrunken  finally,  and  lumps  of  false  hypertrophy,  on 
the  other  hand,  may  appear  in  muscular  groups  otherwise  greatly 
wasted. 

Prognosis. — The  outlook  is  always  unfavorable,  but  some  of  these 
amyotrophies  appear  late  in  life,  and  do  not  apparently  shorten  it.  The 
menace  of  the  disease  falls  upon  the  respiratory  apparatus  and  heart. 
Intercurrent  diseases  also  find  an  easy  prey  in  the  weakened  organism. 

Treatment. — Unfortunately,  all  forms  of  medicinal  treatment  have 
given  negative  results.  Carefully  selected  exercises,  graduated  to  the 
capacity  of  the  weakened  muscles,  promise  the  most  good.  Gowers  early 
insisted  upon  this,  and  Wiener  ^  has  recorded  a  very  encouraging  in- 
stance in  which  much  improvement  was  secured.  Massage  to  the  wast- 
ing muscles  may  have  a  beneficial  effect.  The  application  of  electricity 
is  usually  rendered  impossible  by  the  painfulness  of  the  currents  required 
to  actuate  the  muscles  if  much  wasted,  and  it  is  not  certain  that  its 
vigorous  use  is  harmless.  General  measures  pertaining  to  the  health, 
comfort,  and  education  of  these  unfortunates  will  be  suggested  by  their 
individual  requirements.  Sometimes  a  tenotomy  of  the  heel-tendon  is 
required  to  keep  them  on  their  feet,  but  the  use  of  sustaining  corsets 
and  braces  usually  augments  the  muscular  feebleness  by  depriving  the 
parts  of  their  only  natural  exercise. 

ARTHRITIC  MUSCULAR  ATROPHY. 

All  varieties  of  joiut-disease  may  cause  wasting  of  the  muscles  re- 
lated to  the  joint.  This  occurs  in  two  ways  :  (1)  The  inflammation  may 
involve  nerve-trunks  passing  the  joint,  set  up  a  neuritis  and  produce 
motor,  sensory,  and  trophic  disturbances  in  the  distal  distribution  of  the 
affected  nerves  below  the  diseased  joint.  The  process  is  simply  a  neuritis. 
(2)  The  articular  filaments  may  be  disturbed  by  the  arthritis.  Irritation 
ascends  to  the  spinal  centers  and  disturbs  the  trophic  control  of  those 
cells  related  to  the  muscles  physiologically  associated  with  the  joint  and 
located  on  the  proximal  side  of  the  aifected  articulation.  It  is  a  pro- 
cess acting  through  the  reflex  arc.  We  are  to  consider  the  second 
variety  only.  It  is  placed  in  this  connection  because  it  is  a  disease 
marked  by  disturbance  of  the  spinal  gray  matter. 

Etiology. — Any  joint-lesion  involving  the  articular  filaments  is  com- 
petent to  set  up  an  arthritic  muscular  atrophy.  It  may  thus  follow 
simple,  acute,  or  chronic  arthritis,  infectious  arthritis,  the  arthritis  of 
gonorrhea,  of  rheumatism,  or  of  traumatism.  It  has  no  proportionate 
relation  to  the  severity  of  the  joint-disease,  but  rather  appears  to  be 
relative  to  the  irritant  qualities  of  the  articular  mischief 

Symptoms. — In  acute  joint-lesions  the  muscular  atrophy  usually 
begins  within  a  month,  sometimes  within  a  week,  and  the  muscles 
^  "American  Journal,"  Oct.,  1896. 


408  DISEASES  OF  THE  CORD  PROPER. 

promptly  show  diminished  bulk  and  altered  contours.  In  chronic 
arthritis — for  instance,  in  gout  and  chronic  rheumatism — it  may  very 
gradually  develop,  appearing  very  insidiously  and  requiring  many  months 
for  its  complete  evolution.  The  striking  peculiarity  of  the  atrophy  is 
that  it  is  usually,  and  at  first  always,  confined  to  the  extensors  of  the 
joint,  and  involves  them  in  their  entire  length.  The  only  exception  is 
in  arthritis  of  the  ankle-joint,  in  which  case  the  calf-muscles  waste. 
Arthritis  of  the  shoulder  affects  the  deltoid,  of  the  elbow  the  triceps,  of 
the  wrist  the  extensors,  of  the  fingers  the  interossei,  of  the  hip  the  glutei, 
of  the  knee  the  anterior  crural  nmscles,  of  the  ankle  the  calf-muscles, 
of  the  toes  the  interossei  of  the  foot.  When  the  flexors  are  also  involved, 
they  suffer  to  a  less  degree.  Sensory  disturbances  are  absent,  or  are 
such  as  are  referable  to  the  arthritis.  In  occasional  instances  the  joint- 
inflammation  also  affects  the  nerve-trunks  in  its  neighborhood,  and  a 
neuritis  is  added,  with  symptoms  below  the  joints.  The  wasting  in- 
volves the  affected  muscles  uniformly  from  end  to  end,  and  there  is  a 


Fig.  179.— Severe  arthritic  muscular  atrophy  in  a  case  of  multiple  arthritis. 

corresponding  loss  of  poicer.  The  electrical  excitability  of  the  muscles  may 
be  reduced  slightly,  but  is  generally  increased  relatively  to  the  bulk 
of  muscle  present.  The  reaction  of  degeneration  is  never  found.  The 
tendon  reflexes  are  exalted.  In  very  pronounced  cases  a  rectus-clonus  or 
an  ankle-clonus  may  be  obtained.  When  the  joint-disease  subsides,  the 
tendency  is  for  the  muscles  to  slowly  recover,  but  in  quite  a  proportion 
of  cases  they  never  completely  regain  their  former  vigor,  and  sometimes 
they  remain  permanently  wasted. 

Morbid  Anatomy, — The  atrophic  muscles  are  flaccid,  pale,  and 
inelastic.  The  fibers  are  simply  diminished  in  size  and  there  may  be 
a  little  interstitial  fibrosis.  The  only  change  in  the  nervous  apparatus 
thus  far  recorded  is  in  the  nerve-terminals  within  the  inflamed  joint, 
due  to  their  implication  by  the  local  disease.  Better  technic  may  be 
expected  to  discover  cellular  cord-changes. 

Pathology. — Paget,  J.  K.  Mitchell,  Vulpian,  and  Charcot  early  re- 
cognized the  reflex  mechanism  of  articular  muscular  atrophy,  Yaltat 
found  that  arthritis  experimentally  produced  was  followed  by  the 
limited  atrophy  in  question,  and  Raymond  found  that  this  atrophy  did 
not  follow  if  the  corresponding  posterior  nerve-roots  were  divided. 
Hoffa  clinched  the  matter  by  irritating  joints  on  both  sides  and  cutting 
the  nerve-roots  on  one  side.     The  atrophy  only  occurred  on  the  side 


LESIONS  AND  DISEASES  OF  SPINAL  GRAY.  409 

retaining  an  nnhroken  reflex  arc.  The  anatomical  rule  is  that  nerves 
supplying  the  extensors  of  a  joint  also  innervate  the  joint.  The 
physiological  association  of  arthritis  and  atrophy  limited  to  the  joint- 
extensors  would  in  itself  indicate  the  spinal  element  in  the  pathological 
mechanism.  An  interesting  question  is  whether  the  symmetrical  joint- 
changes  and  osteal  conditions  of  gout  and  chronic  rheumatism  are  not 
primarily  due  to  the  action  of  toxic  substances  upon  the  spinal  cells 
governing  the  nutrition  of  bones  and  joints.  Some  cases  of  panarthritis 
or  multiple  arthritis  symmetrically  distributed,  as  well  as  the  distortions 
of  arthritis  deformans  and  gout,  strongly  suggest  a  central  disturbance 
as  the  principal  and  initial  factor. 

The  diagnosis  of  uncomplicated  arthritic  muscular  atrophv  is 
usually  easy.  It  depends  :  (1)  On  the  limitation  or  excess  of  atrophy  in 
the  extensors  of  a  joint  actively  diseased  or  formerly  arthritic  ;  (2) 
upon  the  quantitative  electrical  changes  and  absence  of  the  reaction  of 
degeneration,  and  (3)  upon  the  increase  of  myotatic  irritability.  A 
microscopic  section  of  the  muscle  would  show  a  simple  diminution  of 
the  muscle-fibers.  When  the  joint-inflammation  invades  adjoining 
nerve-trunks,  a  neuritis  may  at  the  same  time  give  symptoms  below  the 
affected  joint.  The  atrophy  usually  remains  sharply  limited,  in  strong 
contrast  to  the  invading  tendencies  of  progressive  forms. 

The  prognosis  depends  upon  the  joint-condition.  If  the  arthritis 
subsides,  the  atrophy  usually  disappears.  This  is  the  rule  in  acute 
arthritis  with  early  recovery.  In  more  persistent  lesions  the  atrophy 
is  of  corresponding  duration  and  less  likely  to  disappear  when  the  joint 
recovers. 

The  treatment  is  primarily  of  the  joint  and  secondarily  of  the 
muscles,  by  massage,  electricity,  and  gentle  exercises. 


410  DISEASES  OF  THE  CORD  PROPER. 


CHAPTER  IV. 

LESIONS  PRINCIPALLY  AFFECTING  THE  WHITE 
MATTER  OF  THE  CORD* 

There  are  a  number  of  diseases  of  the  spinal  cord  in  which  the 
lesions  are  principally  confined  to  certain  white  tracts,  and  they  are  fre- 
quently classed  among  the  so-called  system  diseases  or  diseases  of 
systematized  lesions.  The  conception  on  which  such  a  classification  was 
based  has  been  so  much  modified  that  it  seems  better  to  drop  it  alto- 
gether, especially  as  there  has  always  been  a  great  divergence  of  opinion 
as  to  what  should  be  embraced  under  that  caption.  Acute  poliomye- 
litis, for  example,  which  was  one  of  the  usually  accepted  types,  is,  as 
we  have  seen,  the  result  of  accidental  infection  by  way  of  the  vascular 
supply.  Posterolateral  sclerosis,  or  ataxic  paraplegia,  is  also  usually  based 
upon  anatomical  vascular  conditions,  and  presents  so  many  variations  that 
it  can  not  be  considered  as  systematized  from  any  point  of  view.  In  loco- 
motor ataxia  the  spinal  lesion  is  as  sharply  delimited  as  in  any  other, 
but  it  is  a  disputed  question  whether  or  not  the  cord-lesion  is  secondary 
to  initial  root-changes.  The  morbid  anatomy  of  the  disease  is  so  wide~ 
spread  that  to  class  it  as  a  systemic  cord-lesion  is  to  seriously  contract 
the  full  view  of  the  disease,  and  to  ignore  its  neuritic  and  cerebral  feat- 
ures. The  secondary  degenerations  of  the  cord-tracts  have  been  con- 
sidered in  connection  with  the  various  cerebral  and  spinal  lesions  which 
give  rise  to  them.  Primary  spastic  paraplegia,  or  Little's  disease,  has 
been  discussed  with  the  Cerebral  Palsies  (see  p.  240),  as  it  is  depend- 
ent upon  a  congenitally  unfinished  condition  of  the  upper  neurons,  and 
furnishes  one  of  the  diplegias  of  childhood. 

Because  the  spinal  symptoms  of  locomotor  ataxia  are  the  most  salient 
of  its  many  manifestations,  and  as  its  diiferential  diagnosis  is  a  constantly 
recurring  problem  in  cord  diseases,  it  is  taken  up  at  this  time.  In  fact, 
however,  it  is  a  disease  of  the  entire  nervous  system  and  must  properly 
be  so  classed.  The  student  should  never  lose  sight  of  the  fact  that 
the  cord-lesion  in  tabes  dorsalis  is  only  a  small  portion  of  its  morbid 
anatomy. 

TABES  DORSALIS:   PROGRESSIVE  LOCOMOTOR  ATAXIA, 

Tabes  dorsalis,  jyrogressive  locomotor  ataxia,  leukomyelitis  posterior, 
sclerosis  of  the  posterior  columns,  are  some  of  the  many  names  applied 
to  a  symptom-group  of  vast  proportions.  It  is  a  disease  almost  always 
preceded  by  a  syphilitic  infection,  usually  marked  by  a  degenerative  pro- 
cess in  the  sensory  nerves,  posterior  nerve-roots,  posterior  columns  of 
the  spinal  cord,  and  often  by  similar  changes  in  the  medulla  and  cerebrum. 
Clinically,  there  is  commonly  disturbance  of  cutaneous  and  joint  sen- 
sation ;  impairment  of  the  muscular  sense ;  inco5rdination  of  muscular 


DISEASES  OF  THE   WHITE  3IATTER  OF  THE  COED.  411 

movements,  especially  in  the  lower  extremities  ;  diminished  or  abolished 
knee  reflexes  and  lessened  papillary  reflexes  to  light ;  visceral  and 
trophic  disturbances  and  paroxysmal  attacks  of  pain.  The  disease  pre- 
sents a  progressive  tendency  toward  complete  helplessness. 

In  the  description  of  this  protean  disease  the  masterly  lectures  of 
Marie  ^  have  been  found  of  great  help,  and  in  some  measure  his  arrange- 
ment of  the  subject  is  followed  herein. 

Etiology. — The  principal  factor  in  the  etiology  of  tabes  dorsalis  is 
syphilis.  It  is  impossible  at  present  to  say  that  it  is  an  indispensable 
element  in  a  given  case,  because  chronic  intoxication  with  ergot  may 
induce  tabetic  features  and  similar  degenerations.  The  same  changes 
are  found  in  pellagra,  and  it  is  at  least  supposable  that  other  toxic 
states  may  lead  to  tabetic  conditions.  Since  attention  was  first  called  to 
the  parasyphilitic  nature  of  locomotor  ataxia  by  Fournier,  in  1875, 
statistics  on  the  subject  have  shown  an  increasing  proportion  of  cases 
presenting  syphilitic  antecedents.  In  1894  ^  he  states  that  in  the  ex- 
amination of  750  cases  he  finds  the  percentage  of  syphilitics  varying 
from  87  to  93  for  each  hundred,  taken  separately.  Erb  reported  89  per 
cent.,  Dejerine,  92  to  94  per  cent,  Sachs  over  90  per  cent.,  Peterson,  71 
per  cent.,  and  the  author,  in  the  last  100  consecutive  cases  occurring  in 
private  practice,  has  failed  to  find  history  or  evidence  of  luetic  infection 
but  twice.  It  is  safe  to  say  that,  practically,  9  out  of  10  cases  are 
syphilitic,  and  that  the  tenth  case  is  open  to  very  serious  doubts  if  it 
occurs  under  ordinary  circumstances  of  life.  Reports  of  cases  of  tabes 
acquiring  syphilis  subsequent  to  the  development  of  ataxia  can  not  be 
obtained.     Such  immunity  argues  prior  infection. 

The  tabetic  symptoms  may  appear  in  from  one  to  thirty-five  years  after 
the  initial  syphilitic  sore,  but  ordinarily  develop  from  the  fifth  to  the 
fifteenth  year.  It  is  a  noticeable  and  most  important  fact  that  the 
apparently  mild  cases  of  syphilis — those  in  which  the  secondary  features 
are  indistinct  or  entirely  lacking — loom  largely  in  the  histories  of  tabetic 
patients.  These  are  precisely  the  cases  in  which  an  intense  medication 
is  not  urged  or  in  which  faithful  pursuit  of  it  by  the  patient  can  not  be 
secured.  It  must  be  said,  however,  that  cases  of  tabes  are  only  too  fre- 
quently encountered  in  which  syphilis  has  run  a  severe  course  and  in 
which  persistent  and  intensive  medication  has  been  heroically  prescribed 
and  faithfully  borne  for  two  and  three  years,  and  yet  tabes  has  subse- 
quently developed. 

It  is  rare  for  tabes  to  develop  before  the  age  of  twenty-five  years, 
just  as  it  is  rare  for  syphilis  to  be  acquired  before  adolescence.  In 
all  cases  appearing  in  childhood,  hereditary  syphilis  is  present.  The 
great  proportion  of  cases  a]>pear  between  thirty  and  forty-five.  As  a 
rule,  the  alleged  etiological  factors  of  tabes,  other  than  syphilis,  are  the 
very  ones  which  contribute  to  the  frequency  of  syphilis.  Thus,  the  male 
sex  is  about  ten  times  as  frequently  affected  with  tabes  as  the  female. 
The  same  proportion  obtains  for  syphilis.  But  among  females  subject 
to  tabes  Erb  found  the  percentage  of  syphilitics  to  be  89.5  per  cent., 
practically  the  same  as  in  males. 

1  "  Lemons  sur  les  Maladies  de  la  Moelle,"  Paris,  1892. 

2  "  Les  affectiones  parasyphilitiques, "  Paris,  1894, 


412  DISEASES  OF  THE  CORD  PROPER. 

The  race  question  tells  the  same  stoiy.  In  rural  communities  and 
among  the  orthodox  Jews  cases  of  syphilis  are  comparatively  rare,  and 
tabes  equally  infrequent.  Excessive  venery  has  been  accused  of  pro- 
ducing tabes.  Its  relation,  if  it  has  any,  is  by  the  increased  exposure 
to  luetic  infection  it  entails.  The  action  of  cold,  rheumatism,  overexer- 
tion, alcoholism,  and  acute  fevers  has  been  much  insisted  upon  in  former 
years,  but  we  know  nothing  definite  about  them.  Many  cases  attributed 
to  traumatism  have  been  misinterpreted  cases  of  organic  indiscriminate 
or  combined  cord-lesions.  In  other  instances  the  accident  leading  to  the 
injur}^  has  been  the  result  of  tabes,  not  its  cause,  as  in  falls  and  fractures, 
the  result  of  the  previously  unrecognized  incoordination.  The  question, 
however,  is  still  debatable.  Prince,^  after  a  critical  examination  of  the 
cases  in  literature,  is  inclined  to  deny  the  traumatic  origin  of  tabes, 

A  neuropathic  heredity  appears  to  play  a  predisposing  part  to  some 
extent.  We  thus  not  infrequently  encounter  epilepsy,  hysteria,  chorea, 
insanity,  hemiplegia,  and  diabetes  in  the  ascendants  of  tabetics,  and 
even,  though  most  rarely,  other  cases  of  locomotor  ataxia.  May  it  not 
be  that  such  instances  indicate  an  inherited  vulnerability  on  the  part  of 
a  certain  portion  of  the  nervous  apparatus  to  the  toxic  effects  of  luetic 
infection  ?  It  must  be  evident  that  only  a  very  small  percentage  of 
syphilitics  develoj^s  tabes. 

The  bearing  of  occupation  is  that  related  to  syphilis.  Artists,  actors, 
journalists,  and  soldiers  are  frequently  affected,  physicians  and  surgeons 
not  infrequently,  clergymen  most  rarely.  Country  laborers,  so  greatly 
exposed  to  traumatism  and  exposure,  very  seldom  present  tabes  or  syphilis. 

In  spite  of  the  immense  importance  of  syphilis  in  the  causation  of 
tabes  dorsalis,  it  must  be  kept  in  mind  that  the  nerve-lesion  is  not  com- 
parable to  the  tertiary  or  secondary  specific  lesions,  and  is  not  amenable 
to  antiluetic  remedies.  It  is  a  degeneration  showing  progressive  sclerotic 
changes  that  are  beyond  repair.  Following  the  views  of  Striimpell  and 
Marie,  we  may  hypothetically  attribute  the  ascending  degenerations  in 
the  nerves,  roots,  spinal  cord,  and  brain  to  the  action  of  a  sx'philitic 
toxin  which  primarily  affects  the  cell-bodies  of  the  fibers  making  up  the 
afferent  tracts. 

Edinger  undertakes  to  explain  the  apparently  selective  activity  of 
the  toxic  agent  upon  certain  physiological  nervous  tracts  and  structures 
by  an  ingenious  hypothesis.  Those  nen'e-elements  which  are  the  most 
constantly  enq)loyed  are  most  affected.  Thus,  the  sensory-  tracts,  espe- 
cially in  the  lower  parts  of  the  cord,  the  pupillary  activities,  the  bladder 
function,  and  the  intestinal  field  are  early  and  commonly  affected.  The 
hypothesis  conjoins  the  elements  of  (1)  fatigue  locally  precipitating  the 
effects  of  (2)  a  general  toxic  state. 

Morbid  Anatomy. — In  this  section  it  is  purposed  to  take  up  the 
morbid  anatomy  of  the  nervous  apparatus  in  tabes  dorsalis.  The  morbid 
anatomy  of  the  trophic  lesions  in  the  bones,  joints,  and  soft  structures 
Avill  be  described  respectively  witli  their  clinical  features.  As  the  disease 
is  essentially  marked  by  ascending  degenerations,  it  is  well  to  commence 
at  the  periphery. 

1  "Jour.  Nerv.  and  Ment.  Dis.,"  Feb.,  1895. 


DISEASES  OF  THE  WHITE  MATTER  OF  THE  CORD. 


413 


The  spinal  nerves:  are  usually  found  to  present  a  degeneration  which 
is  o-reatest  at  the  periphery  and  most  marked  in,  if  not  entirely  confined 
to  the  sensory  fibers  for  the  skin,  muscles,  and  joints.  The  trophic 
centers  for  these  fibers  are  in  the  posterior  root-ganglion  in  part,  but  it 
seems  prolxible  that   there  are  also  superficial   peripheral  trophic  cells 


Fig.  180. — Sections  of  the  cord  in  an  early  case  of  tabes.    1,  Lumbar  region  ;  2,  dorsal  region  ;  3,  cervical 

region  (Marie). 

for  at  least  a  few  of  them.  The  muscle  spindles  which  undoubtedly 
have  a  sensory  function  are  constantly  found  degenerated.  By  some 
writers  these  nerve-changes  are  denominated  a  neuritis,  but  histologically 
the  changes  conform  to  a  Wallerian  degeneration.     The  spinal  nerve-roots 


Fig.  181. — Section  of  cords  in  advanced  tabes.    1,  Dorsal  region  ;  2,  cervical  region.    Sclerosis  shown  hj 

white  region  (Marie). 


present  a  marked  difference  between  the  anterior  or  motor  members, 
which  are  ordinarily  normal,  and  the  posterior  sensory  roots,  which  are 
usually,  if  not  invariably,  greatly  degenerated.  Only  when  changes 
have  taken  place  in  the  anterior  eornual  cells  do  we  find  changes  in  the 
anterior  roots,  and  then  there  is  corresponding  amyotrophy.      This  is 


414 


DISEASES  OF  THE  CORD  PROPER. 


Fig.  182. — Section  in  lower  dorsal 
cord  ill  a  case  of  advanced  tabes  show- 
ing complete  sclerosis  of  the  posterior 
coliiiiins  and  of  Clarke's  cellular  columns 
(Marie). 


usually  a  late  aucl  secondary  or  accidental  feature  in  tabes.     The  posterior 

roots  and  their  ganglia  show  much  disease.     Oppenheim,  Simmerling, 

Marie,  Obersteiner,  ^  Juliusberger  and 
Meyer, 2  describe  changes  in  the  root- 
ganglion  cells,  which  are  found  reduced 
in  size  and  number.  Nuclear  displace- 
ment and  granular  changes  were  de- 
monstrated by  Nissl's  method,  accord- 
ing to  the  last-mentioned  authors.  The 
fibers  within  the  ganglia  were  also 
atrophic.  The  posterior  roots  are  prac- 
tically always  degenerated.  The  poste- 
rior root-ganglion  occupies,  therefore,  a 
prominent  position  in  the  development  of 
tabetic  lesions,  as  it  exercises  a  trophic 
control,  both  downward  over  the  sensory 

fibers  of  the  nerves  and  upward  over  the  posterior  root-fibers  and  their 

continuation  within  the  posterior  tracts  of  the  cord.      Changes  in  the 

visceral  branches  of  the  symjxithetic 

nerves  of  a   degenerative   character 

have  also  been  reported,  and  degener- 
ation of  the  fine  fibers  of  the  sym- 
pathetic   arising    from    the    viscera 

and  entering  the  cord  by  the  poste- 
rior   roots    has    been   demonstrated 

in  a  series  of  cases.  ^ 

To   understand   the  distribution 

of  the  cord-lesions  it  is  necessary  to 

recall  that  the  posterior  root  fur- 
nishes   three    sets  of   fibers,   which 

enter  the  posterior  horn  by  different 

routes  and  at  different  levels.     The 

fibers  of  the  first  group,  almost  as 

soon  as  they  reach  the   cord,  enter 

the  posterior  gray  to  the  inner  side 

of  the  horn  at  its  posterior  third  by 

a   short  route  through  the   tract  of 

Lissauer.    Those  of  the  second  group 

pass  to  the  inner  side  of  the  first  in 

Burdach's    column,   and    enter    the 

middle  third   of  the    horn's    inner 

border  at  a  level  considerably  above 

their  point  of  entrance  to  the  cord. 

Some    of    them    reach    Clarke's 

column.     The    third   group,  arising 

mainly  from  the  lower  limbs,  enter 

still  nearer  the  median  line  and  pass  up  nearly  the  entire  length  of  the 

1  "Berlin,  klin.  Wochens.,"  Oct.  18,  1897.      ^  "Neurolog.  Centralbl.,"  Feb.  15,  1898. 
^  Eoux,  "  Lesions  of  the  Sympathetic  System  in  Tabes,"  Paris,  1900. 


Fig.  183.- Schematic  representation  of  the 
courses  pursued  by  the  sensory  root-fibers  enter- 
ing the  cord  from  the  root-ganglion  (Marie'. 


I)ISEASi:S  OF  THE  WRITE  MATTER  OF  THE  CORD.  415 

cord,  constituting  the  columns  of  Goll,  and  terminate  in  the  bulbar 
gray.  The  tract  of  Lissauer  lying  between  the  head  of  the  posterior 
horn  and  the  periphery  of  the  cord  among  the  entering  posterior-root 
fibers,  is  made  up  of  fine  fibers  arising  from  the  posterior  roots  either 
as  collaterals  or  as  direct  continuations  of  the  numerous  finer  fibers  of 
the  root.  These  fibers  of  Lissauer's  tract,  after  ascending  a  short 
distance,  enter  the  gelatinous  substance  of  Rolando,  which  caps  the 
posterior  horn,  and  some  of  them  penetrate  the  posterior  horn  itself. 
This  tract  also  degenerates  in  tabes. 

Embryologically,  the  posterior  columns  of  the  cord,  including 
Lissauer's  tracts,  are  an  accession  to  the  cord.  They  arise  in  the  lateral 
neural  plaques,  which  are  finally  represented  by  the  posterior-root 
ganglia,  and  enter  the  cord  by  way  of  the  posterior  roots,  pursuing 
their  course  upward  in  the  manner  indicated.  This  part  of  the  cord 
only  reaches  full  development  at  birth.  It  is  to  this  posterior,  exogen- 
ous, independently  developed  portion  of  the  cord-structure  that  the 
spinal  lesions  of  tabes  are  principally  confined. 

These  vary  at  different  levels  and  at  different  stages  of  the  disease. 
In  long-standing  cases  the  entire  portion  of  the  cord  embraced  between 
the  posterior  horns  and  the  commissure  may  be  sclerosed  from  the  filum 
terminale  to  the  medulla.  In  incipient  cases  the  tracts  of  Lissauer  and 
the  columns  of  Burdach  are  affected  at  the  lowest  level,  the  columns  of 
Goll  above.  Ordinarily,  the  sclerotic  changes  of  tabes  are  most 
marked  in  the  lumbar  cord,  where  they  commonly  begin ;  in  other  cases 
the  cervical  enlargement  is  most  affected  ;  again,  in  others,  the  intra- 
cranial lesions  of  the  medulla  predominate,  and  when  associated  with 
cortical  changes  we  have  the  progressive  paralysis  of  the  insane. 
Clinical  varieties  correspond  to  these  various  preponderating  locations 
of  the  sclerotic  process,  and  all  intermediate  varieties  and  combinations 
of  lesions  and  clinical  types  are  encountered.  This  sclerotic  change, 
like  that  in  the  nerves,  is  a  pure  Wallerian  degeneration. 

The  lesions  of  the  spinal  gray  in  tabes,  as  far  as  now  describable, 
consist  of  a  degeneration  of  the  fine  nervous  reticulum  about  the  cells 
of  Clarke's  column  near  the  inner  border  of  the  neck  of  the  posterior 
horns.  The  change  is  an  early  one  and  most  marked  in  the  outer  cells  of 
the  group.  This  reticulum  is  made  up  of  the  terminal  brushes  of  fibers 
from  the  posterior  roots.  Ordinarily,  the  cells  themselves  are  spared, 
but  in  some  cases  they,  too,  show  degenerative  changes,  and  the  direct 
cerebellar  tracts  and  Gowei-'s  ascending  anterolateral  tracts  are  then  also 
sclerotic.  These  two  cord-tracts  find  their  trophic  supply  in  the  cells 
of  Clarke's  column ;  hence  their  degeneration  when  these  cells  are 
affected.  Clarke's  column  begins  in  the  upper  lumbar  segments  and 
extends  to  the  seventh  or  eighth  dorsal,  when  it  becomes  extremely 
attenuated  and  practically  disappears  at  the  second  dorsal,  to  again 
appear  above  the  cervical  enlargement  in  the  upper  cervical  cord.  The 
lesion  of  Clarke's  column  is,  therefore,  most  marked  in  the  lower 
dorsal  region. 

The  posterior  horn  proper,  according  to  Lissauer  and  others,  shows 
only  insignificant  changes  except  in  the  caput  of  Eolando,  where  the 


416  DISEASES  OF  TEE  COBB  PROPER. 

fine  fibers  and  radiating  fibers  from  the  posterior  roots  are  customarily 
degenerated. 

The  cord-lesions  in  tabes  are  commonly  symmetrical,  but  not  infre- 
quently in  early  stages  one  side  will  show  more  sclerosis  than  the  other, 
often  corresponding  to  greater  symptoms  in  the  limb  or  limbs  of  that 
side. 

In  addition,  it  is  to  he  noted  that  there  is  a  clouding  of  the  meninges 
overlying  the  sclerotic  tracts  in  the  spinal  cord,  to  which  much  impor- 
tance has  been  given  by  some  who  see  in  it  a  meningitis  forming  an  , 
initial  pathological  process  in  tabes.  This  and  the  cord-changes  can  be 
frequently  recognized  by  the  eye,  but  in  incipient  cases  recourse  to  the 
microscope  is  required  to  decipher  the  morbid  condition.  In  some 
instances  the  meningeal  condition  reaches  one  of  chronic  inflammation, 
which,  in  turn,  may  cause  a  marginal  myelitis  that  may  even  extend  to 
the  pyramidal  tracts. 

The  cranial  nerves  are  all  liable  to  degeneration,  but  this  tendency  is 
most  marked  in  the  optic  and  auditory  nerves,  which  in  effect  are  cere- 
bral lobes.  Changes  of  a  similar  sort  are  not  rarely  found  in  both 
roots  of  the  trifacial  or  in  the  nuclei  of  the  motor  nerves  of  the  eyeball 
and  of  the  intra-ocular  muscles,  in  the  glossopharyngeal,  pneumogastric, 
facial,  and  hypoglossal.  Involvement  of  the  iridociliary  apparatus  is, 
perhaps,  the  most  common  of  all. 

The  cerebral  lesions  of  tabes,  aside  from  those  of  the  cranial-nerve 
nuclei  or  even  embracing  them,  are  those  of  paretic  dementia,  the 
description  of  which  is  contained  in  the  second  part  of  this  book. 
With  this  disease  tabes  has  the  most  intimate  relations.  Fournier  has 
gone  to  the  point  of  considering  them  of  identical  nature  and  only 
varying  in  the  primary  location  of  the  lesions.  The  parasyj^hilitic 
theory  of  paretic  dementia  rests  on  exactly  the  same  sort  of  a  founda- 
tion as  does  that  of  tabes  dorsalis.  A  certain  proportion  of  cases  of 
tabes  develop  paralytic  dementia  ;  a  large  number  of  paretic  dements 
present  tabetic  symptoms  and  tabetic  cord-lesions.  Both  diseases 
commonly  have  identical  bulbar  and  cranial-nerve  symptoms  and 
lesions.  Though  Jendrassik  tends  to  consider  the  cerebral  lesions  of 
tabes  as  always  initial,  they  are  probably  concomitant  only,  and  due 
to  the  same  specific  cause.  Their  association  in  point  of  time  and 
development  is  open  to  all  possible  modifications  throughout  all  the 
varieties  of  each  aifection.  The  most  pronounced  types  of  both  syn- 
dromes are  presented  as  the  sclerotic  process  falls  first  and  most  severely, 
respectively,  on  the  caudal  or  cephalic  extremity  of  the  cerebrospinal 
system. 

Symptoms. — From  the  extent  of  the  morbid  anatomical  changes  in 
tabes  it  must  be  evident  that  its  symptomatology  embraces  nearly  eveiy 
bodily  organ  and  function.  The  clinical  features  of  the  disease  can  only 
be  fully  presented  by  taking  them  up  systematically.  Afterward  an 
attempt  will  be  made  to  group  them  in  describing  the  common  clinical 
varieties  of  the  malady.  As  we  proceed,  the  relation  of  the  various 
symptoms  to  the  course  of  the  disease  will  be  indicated.  Their  rela- 
tive frequency  will  be  shown  in  tabular  form. 


DISEASES  OF  THE  WHITE  MATTER  OF  THE  COED.  417 

Motor  Disturbances. — Tlie  motor  disturbances  of  tabes,  while  not 
the  earliest,  are  among  the  most  important,  and  are  the  ones  which 
usually  first  seriously  attract  the  patient's  attention.  They  consist  of: 
(1)  ataxia;  (2)  involuntary  movements,  and  (S)  jxdsies. 

Tabetics  deprived  of  their  muscular  sense  by  the  posterior  sclerosis 
or  by  the  degeneration  of  the  peripheral  sensory  fibers  in  the  muscles 
and  joints  can  not  determine  the  exact  positions  of  their  limbs  without 
the  aid  of  vision.  This  is,  no  doubt,  increased  to  some  extent  if  attended 
by  cutaneous  dysesthesia,  which  is  frequently  present.  They  thus  "  lose 
their  legs  in  the  bed  "  in  marked  cases,  and  have  to  verify  the  position 
of  their  limbs  with  their  hands  or  eyes.  In  less  pronounced  cases  they 
can  not  with  closed  eyes  duplicate  with  one  limb  the  position  passively 
given  the  other  by  the  examiner,  or  do  so  with  uncertainty.  Another 
manifestation  of  the  perturbation  of  the  muscular  sense  is  an  inability 
to  accurately  distinguish  the  difference  in  weight  of  similarly  shaped 
objects  held  in  the  hands.  The  normal  individual  can  usually  deter- 
mine a  cliiFerence  of  five  per  cent.  This  symptom  can  sometimes  be  shown 
by  having  the  patient  first  write  a  short  sentence  with  open,  and  then 

Fig.  184. — Ataxia  of  the  upper  extremities  shown  in  the  handwriting.    1,  Written  with  eyes  open; 

2,  with  closed  eyes. 

repeat  it  with  closed,  eyes.  The  uncertainty  of  position  and  the  conse- 
quent incoordination  is  then  sometimes  graphically  demonstrated,  while 
grosser  movements  with  the  upper  extremities  may  be  tolerably  exact. 
Many  patients  fail  to  touch  the  nose  or  ear  or  any  given  point  with  the 
index-finger  when  the  eyes  are  closed. 

Tabetics  commonly  present  the  sign  of  Romberg  early  if  the  lower 
portion  of  the  cord  is  involved.  With  closed  eyes  they  sway  or  may  fall 
heavily  if  the  feet  are  placed  close  together,  and  may  even  be  unable  to 
stand  with  a  broad  base  of  support.  A¥alking  backward  with  closed 
eyes  will  almost  invariably  determine  incoordination  in  the  lower  ex- 
tremities if  present  in  the  slightest  degree.  So  will  attempts  to  stand 
on  one  foot.  In  advanced  cases  this  loss  of  muscular  sense  causes  so 
marked  an  ataxia  that  walking  is  impossible,  even  with  the  eyes  open. 

To  this  source  we  must  also  attribute  the  ataxic  gait  that  is  so  char- 
acteristic when  well  developed.  It  by  no  means  appears  clearly  in  all 
cases,  but  may  usually  be  induced  to  some  degree  by  having  the  patient 
walk  with  closed  eyes,  or  may  be  manifest  in  the  difficulty  of  executing 
a  prompt  "about  face,"  in  suddenly  rising  from  a  chair  and  attempting  to 
immediately  walk  forward,  in  descending  a  stair,  in  halting  suddenly 
when  advancing,  and  in  marking  time  after  the  military  fashion.  In 
27 


418 


DISEASES  OF  THE  COED  PRO  PES. 


crossing  one  knee  over  the  other  the  moving  limb  is  often  raised  too 
high  and  too  vigorously  dropped  across  its  fellow.  When  the  gait  is 
plainly  ataxic,  the  patient  rises  from  the  chair  with  some  suddenness,  as 
if  lifted  by  a  spring,  then  balances  a  moment  before  putting  himself  in 
motion.  The  first  steps  are  usually  taken  briskly  and  the  patient  may 
even  plunge  forward.  The  legs  are  thrown  out  widely.  The  foot  goes 
forward  irregularly  with  some  rigidity,  the  toe  up,  often  departing  later- 
ally from  the  direct  line,  and  is  brought  down  with  a  shock  upon  the 
heel,  or  flat-footed.  As  the  body  is  advanced,  there  is  a  tendency  to 
overextension  of  the  supporting  knee-joint,  which  often  produces  a 
backward  bowing  of  the  limb  and  may  constitute  a  marked  deformity. 


Fig.  185.— Gait  in  tabes.  Observe  over- 
extension of  supporting  knee,  rigidity  of  ad- 
vancing leg,  elevated  toe,  heavily  descending 
heel,  watchfulness  of  steps,  and  assistance  by 
cane. 


Fig.  186. — Showing  the  tendency  to  over- 
extension of  the  knee-joints  in  tabes,  to  secure 
iirniness  in  standing. 


Tlie  foot  is  usually  raised  too  high  at  the  end  of  the  step,  but  is  also 
prone  to  catch  upon  any  trifling  obstacle  as  it  swings  forward.  The 
opposite  foot  is  then  advanced  in  a  similar  irregular  way,  and  the  patient 
almost  invariably  aids  himself  by  carefully  watching  his  feet  and  bythe 
additional  assistance  of  one  or  two  canes  (Fig.  185).  In  some  cases 
there  is  considerable  uniformity  in  the  manner  of  taking  each  step,  but 
as  often  no  two  paces  are  exactly  alike,  and  the  patient,  instead  of 
advancing  in  a  straight  line,  swerves  more  or  less  to  one  and  the  other 
side,  often  bumping  into  neighboring  objects. 

When  he  sits  clown  he  does  so  with  suddenness,  as  if  both  knees 
gave  way  too  soon,  as  they  often  do.  In  the  same  way  he  can  not  grad- 
ually lower  himself  from  the  erect  position  to  a  squatting  attitude,  but 
drops  suddenly  when  the  knees  are  partially  bent.      The  sudden  giving 


DISEASES  OF  THE  WRITE  MATTER  OF  THE  CORD.  419 

way  of  a  knee  sometimes  causes  him  to  fall,  and,  as  a  rule,  his  attitude 
and  gait  denote  every  effort  to  trust  these  joints  as  little  as  possiljle  and 
to  fix  them  by  overextension. 

When  the  upper  extremities  are  markedly  ataxic,  it  is  shown  in  the 
manner  of  grasping  a  small  article,  toward  which  the  hand  goes  with 
wide-spread  fingers,  and  grabs  down  on  it  as  if  it  might  escape  Ijy  flight. 
Finally,  walking  becomes  impossible,  and  the  upper  extremities  may  be- 
come useless  except  for  wide  and  inexact  movements.  Commonly  inco- 
5rdination  is  most  marked  in  the  lower  extremities,  but  in  the  cervical 
type  of  tabes  the  condition  may  be  more  pronounced  in  the  arms.  In 
all  these  motor  affections,  however,  muscular  power  is  not  necessarily 
impaired.  It  is  only  the  muscular  sense  that  fails.  The  ataxia  is 
commonly  of  insidious  development,  but  in  some  instances  comes  on 
abruptly,  usually  as  the  result  of  some  physical  strain  or  exhausting 
condition  or  after  a  period  of  disuse  of  the  limbs,  as,  for  instance,  after 
an  illness  or  fracture.  In  cases  where  it  is  slowly  increasing  it  may 
show  sudden  intensification,  some  of  which  may  recede,  but  rarely  does 
such  sudden  increase  of  ataxia  fully  pass  away. 

Involuntary  movements  in  tabes  dorsalis  are  not  uncommon,  and  prob- 
ably more  frequent  than  reports  indicate,  as  they  are  obscured  by  the 
major  features  due  to  incoordination.  In  the  early  as  in  the  late  stages 
they  may  be  observed  in  some  cases,  and  usually  are  uniform  for  the 
given  patient.  They  may  consist  of  a  sudden  involuntary  movement  of 
the  thumb  or  a  finger,  or  the  turning  of  the  wrist,  or  the  jerking  of  the 
arm  or  foot.  In  a  case  now  under  observation  the  entire  lower  extrem- 
ity is  frequently  violently  jerked,  mainly  by  the  flexors  of  the  hip,  and 
these  movements  may  be  repeated  rapidly,  but  irregularly,  for  sevei'al 
minutes,  and  even  for  an  hour  or  two  daily,  irrespective  of  fatigue  or 
position.  Such  jerkings  of  the  legs  are  prone  to  occur  during  sleep. 
In  exceptional  cases  and  in  their  terminal  stages  both  lower  extremities 
may  be  forcibly  drawn  up  to  the  body.  This  occurs  upon  coughing^ 
sneezing,  or  sometimes  upon  voluntary  efforts  of  any  sort  or  even  upon 
the  manipulation  of  the  extremities.  The  slighter  movements  have 
been  called  athetoid  by  some,  but  they  present  nothing  in  common  with 
the  true  athetotic,  vermicular  movements  so  common  in  the  cerebral 
palsies  of  children. 

Fraenkel  has  recently  emphasized  the  fact  that  myoidism  is  easily  pro- 
voked, in  the  muscles  which  show  diminished  reflexes,  by  sharplv  pinch- 
ing them,  or  by  a  smart  light  blow  with  a  ruler,  at  right  augles  to  their 
length. 

Palsies. — The  paralytic  features  in  tabes  are  of  two  orders,  and  are  to 
be  clearly  distinguished  from  the  loss  of  coordinate  power  which  consti- 
tutes the  major  motor,  difficulty.  (1)  One  is  due  to  the  wasting  of  the 
muscles,  a  result  of  the  involvement  of  the  anterior  horns  of  the  cord, 
usually  appearing  late  in  the  disease ;  (2)  the  second  group,  to  which 
attention  is  here  confined,  is  the  result  of  organic  or  vascular  changes 
in  the  cerebrum  or  cord.  They  appear  in  about  one-fifth  of  the  cases, 
and  embrace  hemiplegia,  facial  paralysis,  lingual  paresis,  monoplegias, 
laryngeal  palsy,  and  paraplegias,  the  last  being  due  to  focal  disturbance 


420  DISEASES  OF  THE  CORD  PBOPEB. 

in  the  cord.  In  addition,  paralytic  drooping  of  the  lid  constituting 
ptosis,  one  of  the  early  manifestations  of  tabes,  may  be  mentioned,  but 
will  be  more  fully  described  under  disturbances  of  the  ocular  apparatus. 
The  facial  palsy  also  may  be  neuritic. 

A  peculiarity  of  these  palsies,  as  pointed  out  by  Fournier,  who  has 
tabulated  them,  is  their  usual  benign  and  fleeting  character.  They  may 
last  some  days  or  a  few  weeks,  when  they  may  completely  and 
spontaneously  disappear,  but  a  minority  of  the  palsies  remain  per- 
manently. Some  of  these  transitory  cases  undoubtedly  are  to  be 
referred  to  hysteria,  which  not  infrequently  is  a  complication  of  tabes. 
The  permanent  cases  are  probably  due  to  vascular  or  inflammatory 
accidents  in  the  brain  or  cord ;  in  other  instances  a  neuritis  may 
determine  a  localized  loss  of  power. 

Sensory  Disturbances. — The  sensory  disturbances  in  locomotor 
ataxia  are  among  the  very  earliest  to  appear,  and  persist  in  some  form 
or  other  throughout  the  course  of  the  disease.  They  are  rarely  the 
same  in  any  two  patients,  and  may  vary  almost  infinitely  in  a  given 
case. 

Subjective  Sensory  Disturbances. — The  first  group  of  sensory  disturb- 
ances are  those  of  a  subjective  nature,  regarding  which  we  have  to  de- 
pend entirely  upon  the  descriptions  of  the  patient.  They  may  be  subdi- 
vided into  those  which  are  intermittent  and  those  Avhich  are  permanent. 
First  and  most  important  of  the  intermittent  variety  are  the  so-called 
lightning  paiTis,  which  are  experienced  in  the  face,  extremities,  or  trunk, 
but  most  commonly  in  the  legs.  They  are  described  in  the  most  vigor- 
ous language  and  the  most  striking  terms  by  these  unfortunate  sufierers, 
are  clearly  atrocious  in  character,  and  are  not  associated  usually  with 
any  evidence  of  disturbance  in  the  part  where  they  locate.  Pains  of  a 
similar  character,  but  somewhat  less  in  intensity,  and  transitory  like 
the  lightning  pains,  are  lancinating,  boring,  biirniny,  twisting  sensations 
of  a  painful  character.  In  each  patient  an  attack  of  such  pain  is 
likely  to  be  followed  by  a  similar  attack  in  a  similar  location,  and  these 
attacks  or  crises  occur  in  some  cases  with  a  degree  of  regularity  every 
week,  month,  or  year.  Ordinarily,  they  are  attributed  to  rheumatism, 
and  it  is  not  uncommon  for  patients  to  be  treated  for  rheumatic  disturb- 
ance for  months  and  even  years  before  the  tabetic  nature  of  the  painful 
affection  is  recognized.  A  careful  examination  in  a  case  marked  by 
repeated  painful  attacks  will  almost  invariably  determine  other  evi- 
dences of  tabes.  The  diagnosis  should  be  made.  When  commencing 
early  in  the  disease,  the  pains  may  disappear  after  the  ataxia  has 
become  prominent,  but  if  they  do  not  appear  in  the  early  stage  they  are 
not  likely  to  appear  later.  In  some  cases  they  persist  through  the 
entire  duration  of  the  disease. 

Another  variety  of  subjective  pains  are  associated  with  the  viscera, 
and  constitute  anal,  testicular,  ovarian,  urethral,  vesical,  gastric,  laryngeal, 
and  intestinal  crises,  which  will  be  taken  up  in  the  consideration  of  the 
visceral  disturbances  of  the  disease. 

Tabetics  also  frequently  complain  of  attacks  of  muscular  cramps, 
which,  like  the  lightning  pains,  have  a  tendency  to  come  on  in  gusts, 


DISEASES  OF  THE  WHITE  MA  TTER  OF  THE  CORD. 


421 


and  frequently  compel  the  patient  to  take  to  his  bed.  Their  common 
location  is  in  the  muscular  masses  of  the  lower  extremities  or  in  the 
small  of  the  back. 

The  second  class  of  pains  is  more  permanent  in  cliaracter,  lasting 
weeks,  months,  or  even  years,  perhaps  appearing  and  disappearing  sev- 
eral times  during  the  course  of  the  disease.  One  of  the  most  important 
of  these  is  the  c/irdle  sensation.  The  patient  describes  it  as  the  feeling 
of  a  tight  belt,  and  may  frequently  attempt  to  relieve  it  by  loosening 
his  clothing.  It  may  be  situated  in  the  lower  portion  of  the  abdomen, 
or  at  the  level  of  the  umbilicus,  or  about  the  chest.  It  is  usually  rather 
narrow  in  its  vertical  extent,  but  may  be  of  considerable  width,  giving 
rise  to  sensations  of  an  iron  or  rigid  corset.  An  analogous  sensation  is 
sometimes  felt  in  the  extremities  as  of  a  bracelet,  or  as  if  the  legs  or  arms 
were  wound  with  rope.  Paresthetic  sensations  of  a  more  or  less  per- 
sistent character  are  described  by  the  patient  as  the  creeping  of  ants  or 
insects,  a  feeling  of  fullness  in  certain  parts  of  the  body,  especially  along 
the  ulnar  border  of  the  forearm  and  hand,  and  in  the  lower  extremities 
below  the  knees.  In  other  cases  the  sensation  is  that  of  a  cobweb  or 
some  liglit  fabric  upon  the  skin. 

Sensory  Disturbances  Partially  Objective. — Analgesia  is  one  of 
the  commonest  manifestations  of  tabes,  aifecting  not  only  the  cutaneous 
extent,  but  the  muscles,  bones,  and  joints.  Even  dislocations  and  frac- 
tures, perforating  ulcers,  and  other  diseases  of  the  deeper  parts,  as  well 
as  of  the  skin,  are  frequently  unattended  by  pain.  Very  often  the 
patient  is  unaware  of  the  analgesia  and  is  surprised  to  observe  that  a 
needle  can  be  thrust  deeply  into  the  tissues  without  giving  rise  to  any 
discomfort.  This  loss  of  the  sensation  of  pain  is  frequently  distributed 
in  plaques  upon  the  trunk  and  extremities  without  reference  to  the  ordi- 
nary manifestations  of  the  disease,  and  does  not  spare  the  surface  of  the 


Fig.  187.  —Tabetic  cuirass  of  blunted  tactile  sensation. 


head.  It  has  a  tendency  to  symmetry,  affecting  both  upper  extremities, 
both  lower  extremities,  or  the  trunk  bilaterally.  On  the  head,  liow^ever, 
there  is  a  tendency  to  a  unilateral  distribution  of  the  analgesia.  On  the 
trunk  the  most  common  location  for  the  analgesia  is  over  both  pectoral 
regions,  about  the  umbilicus,  in  each  inguinal  region,  and  over  the 
shoulders.      Frequently  these  analgesic  plaques  are  marked  by  a  hyj)er- 


422  DISEASES  OF  THE  CORD  PROPER. 

esthetic  border.  On  the  upper  extremities  the  analgesia  most  commonly 
affects  the  fingers  or  the  ulnar  border  of  the  forearm.  In  the  lower 
extremities  it  is  the  sole  of  the  foot,  the  heel,  and  the  toes ;  on  the 
thighs  the  inner  surface,  corresponding  to  the  adductors.  The  nerve- 
trunks,  as  the  ulnar  at  the  elbow  and  the  external  popliteal  at  the  head 
of  the  fibula,  are  frequently  found  insensitive  in  very  early  stages  of 
the  disease.  The  testicle  may  also  lose  its  normal  sensitiveness  to 
pressure. 

On  the  trunk  is  frequently  found  what  may  be  denominated  the 
tabetic  cuirass.  In  about  four-fifths  of  the  patients,  even  at  an  early 
stage,  there  appears  a  band  about  the  chest,  which  may  be  most  marked 
on  the  anterior  or  more  commonly  the  posterior  surface,  or  rarely  con- 
fined to  the  pectoral  regions.  This  area  presents  a  diminished  sensation 
to  touch  (Laehr,  Patrick,  Bonar).  Its  outline  above  and  below  is  some- 
times hyperesthetic.  It  varies  in  vertical  width  from  three  or  four 
inches  to  an  area  which  would  be  covered  by  a  corset,  and  is  sometimes 
associated  with  a  girdling  sensation.  This  cuirass  distribution  is  not 
ordinarily  one  of  analgesia,  but  of  tactile  loss,  though  it  may  be  both. 
Its  limits  are  those  of  the  cutaneous  extent  of  the  spinal  segments,  and 
do  not  conform  to  the  course  of  the  intercostal  nerves.  These  areas  of 
tactile  anesthesia  have  four  principal  localizations  :  (1)  In  horizontal 
patches  or  girdles  on  the  trunk  ;  (2)  the  internal  surface  of  arms  and 
forearms  and  ulnar  borders  of  hands ;  (3)  the  perineal  and  genital 
regions  ;  (4)  the  outer  margins  of  the  feet,  outer  sides  of  legs,  and  the 
anterointernal  surfaces  of  the  thighs.  They  are  often  related  ^  to  the 
painful  disturbances  of  neighboring  viscera. 

Hyperalgesia  is  a  common  condition  in  tabes.  It  may  appear  in 
plaques  similar  to  those  of  analgesia,  but  has  less  tendency  to  symmetry 
of  distribution  and  is  less  persistent.  These  hyperalgesic  plaques  fre- 
quently are  the  foci  of  lightning  pains  and  often  appear  during  the 
painful  crises.  Hyperalgesia  may  be  found  not  alone  for  the  painful 
stimulus  of  the  needle,  but  for  cold  and  other  sources  of  pain.  Many 
patients  in  the  early  years  of  the  disease  find  hot  water  intolerable  in 
the  bath  and  frictions  by  hand  or  towel  almost  unbearable. 

In  some  instances  the  stereognostic  sense  is  materially  impaired  and  in 
a  ratio  disproportionate  to  other  sensory  modifications.  ^  Thus,  in  the 
h^nds,  which  may  be  the  seat  of  only  slight  paresthesia,  a  match-box 
may  not  be  told  from  a  coin  and  other  familiar  objects  similarly  mis- 
taken or  unrecognized. 

Modifications  of  the  cutaneous  sensations  are  quite  frequent.  Com- 
monly the  transmission  of  sensation  from  the  extremities  is  retarded^  so 
that  the  patient,  when  instructed  to  do  so,  does  not  indicate  the  percep- 
tion of  the  pin-prick  upon  his  shin  or  foot  within  a  period  of  three, 
five,  or  even  ten  seconds,  or  more.  In  a  general  way  the  retardation 
of  the  transmission  of  sensation  increases  with  the  distance  of  the  part 
from  the  head,  not  only  because  of  the  distance,  but  from  the  fact  that  tlie 
extremities  usually  present  the  greater  disturbance  of  sensation,  probably 

1  Marinesco,  "Sem.  Med.,"  Oct.  13,  1897. 
^Rennie,  "Br.  Med.  Jour.,"  Feb.  7,  1903. 


DISEASES  OF  THE  WHITE  3IATTEB  OF  THE  CORD.  423 

owing  to  the  changes  in  the  distal  ramifications  of  the  sensory  nerves. 
A  peculiarity  is  that  the  retardation  of  sensation  may  be  dissociated. 
Painful  sensation  may  be  retarded,  while  that  for  touch  is  not,  so  that 
the  patient  feels  the  prick  of  a  pin  immediately  as  a  touch  and  subse- 
quently as  a  pain.  Frequently  patients  are  unable  to  distinguisn  the 
character  of  the  stimulating  impression,  recognizing  a  prick  as  a  pinch. 
This,  in  other  words,  is  an  expression  of  the  diminution  of  their  sensi- 
tiveness. Tabetics  may  fail  to  properly  locate  the  stimulus, — a  pinch 
on  the  foot  may  be  referred  to  the  knee  or  to  the  opposite  foot.  In 
general,  the  tactile  sensations  are  abolished  later  and  to  a  less  degree 
than  sensations  of  pain,  but  they  are  also  frequently  modified,  and  this 
gives  rise  to  additional  difficulty  in  locomotion.  The  patients  express 
themselves  as  having  a  feeling  of  walking  upon  a  thick  carpet,  upon 
cushions,  upon  rubber,  or  other  yielding  substances. 

It  may  be  found  that  a  stimulus  not  at  first  recognized  is  appre- 
hended upon  being  repeated  a  few  times  with  some  rapidity,  the  summa- 
tion of  effects  being  competent  to  reach  a  sensorium  cut  off  from  a 
single  impulse.  Again,  a  stimulus  at  first  competent  may,  upon  repe- 
tition, fail  to  rouse  the  sensorium  by  exhaustion  apparently  of  the 
conduction  apparatus  which,  after  a  short  interval  of  rest,  again  responds 
to  the  original  excitation.  Even  the  syringomyelic  dissociation  of 
cutaneous  sensibility  has  been  encountered  in  tabes,  but  commonly  it  is 
devoid  of  those  exact  and  equal  boundaries  for  all  forms  of  sense 
anomalies  which  are  found  in  the  true  syringomyelic  syndrome.^ 

In  all  cases  it  is  necessary  to  use  the  utmost  caution  in  making  tests 
of  sensation,  as  already  indicated  in  Part  I.  Some  allowance  also  must 
be  made  for  the  intelligence  and  temperament  of  the  given  patient. 

Disturbance  of  the  Reflexes. — The  knee-jerks  are  lessened,  un- 
equal, or  more  frequently  abolished,  and  that  at  an  early  stage  of  tabes, 
in  at  least  nineteen  out  of  twenty  cases.  The  lost  knee-reflex,  often 
called  WestphaVs  sign,  must  be  sought  with  great  care,  but  in  no 
instance  should  the  patellar  reflex  be  considered  extinct  unless  the  plan 
of  reinforcement  and  all  precautions  are  taken  to  elicit  it.  It  may  also 
be  well  to  recall  that  it  is  diminished  in  advanced  age,  in  sleep,  by 
fatigue,  in  exhausting  illness,  and  by  any  condition,  such  as  a  peripheral 
neuritis,  that  destroys  the  afferent  and  efferent  paths  or  the  spinal 
center.  It  is  also  possible  that  very  rarely  a  healthy  adult  may  be 
found  without  a  knee-jerk.  The  Achilles  i^ejlex  ordinarily  fails  with  the 
knee-jerk.  In  fact,  it  may  disappear  before  the  knee-jerk  is  lost  and 
constitutes  a  valuable  early  test.  The  reflexes  in  the  upper  extremity 
fail  when  the  cervical  cord  is  involved,  and  Fraenkel  claims  that  the 
triceps  reaction  is  lost  as  commonly  and  as  early  as  the  knee-jerk.  ^ 
The  superficial  reflexes,  such  as  the  plantar,  abdominal,  dorsal,  and 
scapvdar,  are  variable.  The  iris  reflex  to  light  is  usually  abolished  eaily, 
but  will  be  considered  later  with  the  disturbances  of  certain  other 
organic  reflexes,  including  those  of  the  cremasters. 

All  muscles  in  the  involved  areas  present  a  peculiar  lack  of  tonicity, 
of  which  the  reduced  or  lost  tendon  reflexes  are  a  manifestation.      This 

^  Eaymond,  "Lemons,"  Paris,  1901.        ^  "  Deutsch.  Zeit.  f.  Nervenh.,"  July,  1900. 


424 


DISEASES  OF  THE  COED  PROPER. 


livpotone  is  readily  demonstrated  by  the  ease  with  which  over-extension 
can  be  imparted  to  knees,  ankles,  and  elbows,  and  in  the  great  range 
of  flexion  at  the  hip  and  of  abduction  of  the  thighs. 


Fig.  188.— Abnormal  range  of  flexion  of  hip-joint  due  to  hypotonus  in  tabe.s. 


Fig.  189.— Abnormal  abduction  of  thighs,  the  "  split"  position,  due  to  hypotonus  in  tabes. 


Fig.  190. — Abnormal  flexibility  of  spine  and  hips  in  tabes  due  to  hypotonus. 


DISEASES  OF  THE  WHITE  MATTER  OF  THE  CORD. 


425 


Disturbance  of  the  Visual  Apparatus. — Both  the  external  and 
internal  porti(jns  of  the  ocular  mechanism  are  frequently  impaired  in 
tabes. 

Ptosis  and  squints,  usually  unilateral,  sometimes  bilateral,  are  of  com- 
mon occurrence  in  the  preataxic  as  well  as  in  the  later  stages  of  loco- 
motor ataxia.  They  may  be  and  often  are  temporary  and  fleeting,  almost 
momentary,  but  show  a  marked  tendency  to  recur  and  occasionally  are 
permanent.  Careful  questioning  will  commonly  recall  to  a  tabetic's 
mind  some  such  ocular  experience.  Its  temporary  character  is  the  best 
evidence  of  its  tabetic,  we  may  even  say  of  its  syphilitic,  nature.  Any 
of  the  extrinsic  muscles  of  the  eye  may  be  selected  by  the  disease,  but 
those  under  the  control  of  the  third  cranial  nerve  show  more  than  their 
due  proportion  of  paralytic  disturbances.  They  may  be  gradually  in- 
vaded, and  a  progressive  external  ophthalmoplegia  results  with  perma- 
nent disability.  Lacnmation,  exophthalmos,  enophthalmos,  nystagmus, 
and  reduced  ocular  tension  on  one  or  both  sides  has  been  noticed  in  rare 
instances. 

The  pupils  are  aifected  in  the  great  majority  of  tabetic  cases,  and 
furnish  some  of  the  earliest  and  most  important  diagnostic  symptoms. 
Every  possible  pupillary  modification  may  be  encountered  in  tabes, — 
inequality,  irregularity,  miosis,  mydriasis,  sluggishness,  loss  of  light  reflex, 
loss  of  accommodation  reflex,  loss  of  reflex  to  pain,  and  absolute  iridoplegia. 
There  is  only  one  other  disease  that  has  a  parallel  in  this  matter  of 


/80 


Fig.  191. — Contracted  irregular  visual  fields  in  tabetic  optic  atrophy.     1,  Left  eye;  unbroken  line 

bounds  form  field,  broken  line bounds  field  for  red  in  which  there  is  a  blind  scotoma  ;  small  central 

field  is  for  green  ;  2,  right  eye ;  unbroken  line  bounds  form  field  ;  small  inner  field  is  for  green. 


pupillary  disturbance,  and  that  is  paretic  dementia.  The  analogy,  if 
not  identity,  of  these  diseases  has  been  sufficiently  indicated.  These 
various  pupillary  disorders  may  be  combined  in  any  and  every  way. 
Sluggishness  of  the  pupils  to  light  and  slight  inequalities  and  irregular- 
ities of  outline  are  usually  encountered  very  early  in  the  disease.  I^ater, 
contracted  pupils  .still  responding  to  accommodative  efforts  but  not  to 
light,  constituting  the  Robertson  piqnllary  sign,  are  noted,  and  still  later 


426  DISEASES  OF  THE  COBB  PROPER. 

loss  of  reflex  to  pain,  and  eventually  complete  iricloplegia,  with  or  with- 
out paralysis  of  accommodation,  is  often  found.  Dilated  pupils  may  be 
subsequently  contracted,  but  pupils  once  contracted  to  an  extreme  degree 
very  rarely  again  dilate  widely.  The  fixed  pupils  of  tabes  resist  agents 
that  ordinarily  control  the  pupillary  muscles,  and  if  forced  from  their 
abnormal  proportions,  as  by  belladonna,  return  to  them  oidy  after  sev- 
eral weeks.  The  dissociation  of  the  light  and  accommodative  reflex  is, 
perhaps,  the  most  important  of  all  ocular  symptoms,  and  appears  early 
in  over  one-half  of  all  cases.  Over  seventy  per  cent,  of  tabetics  show  _ 
some  pupillary  disturbance. 

The  opiic  nerve  degenerates  in  about  ten  per  cent,  of  tabetics,  and 
this  occurs  in  those  patients  who  have  shown  ocular  palsies  more  fre- 
quently than  in  others.  The  optic  atrophy  is  usually  bilateral,  but  has 
a  tendency  to  attack  the  left  eye  first.  Its  natural  termination  is  in 
blindness.  In  rare  instances  it  comes  to  a  standstill,  or  even  recedes  a 
trifle.  It  may  cause  blindness  in  a  few  months,  or  many  years  may  be 
required  for  the  extinction  of  sight.  As  a  matter  of  fact,  the  optic 
atrophy  may  have  advanced  to  a  considerable  development  before  the 
patient  notices  any  visual  impairment.  The  order  of  symptoms  is  usu- 
ally :  (1)  A  contraction  of  the  color-fields,  green,  red,  and  blue  fading 
in  the  order  named ;  (2)  the  form-field  shrinks,  and  (3)  vision  begins  to 
diminish.  The  retraction  of  the  field  is  usually  most  pronounced  on  the 
temporal  side,  but  may  be  irregularly  concentric.  In  occasional  instances 
hemianopsia  or  quadrant  defects  have  been  observed,  and  even  central 
scotomata.  These  partial  fields  are,  perhaps,  properly  attributed  to  a 
retrobulbar  neuritis.  The  characteristic  ophthalmoscopic  picture  from 
the  first  shows  a  blanching  of  the  papilla,  which  becomes  grayish  or 
bluish-white  and  pearly.  Its  border  is  sharply  defined,  and  sometimes 
it  is  stippled  by  the  cribriform  markings.  Eventually  the  vessels  diminish 
in  size,  first  the  arteries,  then  the  veins. 

Optic  atrophy  may  be  a  very  early  tabetic  feature,  and  usually  ap- 
pears either  before  or  during  the  early  portion  of  the  ataxic  stage,  while 
the  patient  is  still  walking  fairly  well.  It  is  a  clinical  fact  of  much  value 
that,  as  a  rule,  the  cases  developing  optic  atrophy  early  do  not  show 
much  ataxia,  and  the  locomotor  difficulties  are  only  those  of  blindness. 
When  appearing  in  the  ataxic  stage  there  is  little  or  no  further  increase 
of  incoordination,  and  in  certain  cases  the  ataxia  almost  or  quite  disap- 
pears.    Benedikt  says  it  invariably  subsides. 

Auditory  Symptoms. — Morpurgo  ^  has  shown  that  eighty  per  cent, 
of  tabetics  present  auditory  defects  which  may  appear  early  or  late  in 
the  disease. 

The  auditory  nerve  is  subject  to  a  degeneration  similar  to  that  noted 
in  the  optic  and  about  as  frequently.  In  other  instances  the  disturbance 
is  in  the  middle  or  external  ear.  The  impairment  of  hearing  is  frequently 
insidious  and  extremely  slow  in  reaching  a  complete  degree,  but  in  some 
cases  comes  on  with  rapidity  or  even  abruptly.  It  is  usually  bilateral 
but  commonly  more  marked  on  one  side  than  upon  the  other.  The  dis- 
tinction between  disease  of  the  nerve  and  disease  of  the  conduction  appa- 
1  "Archiv.  f.  Ohreuheilk.,"  1890. 


DISEASES  OF  THE  WHITE  MATTER  OF  THE  COED.  427 

ratiis  is  determined  by  liinne's  test  (see  page  64).  Weber's  test,  which 
consists  of  placing  the  handle  of  a  vibrating  tuning-fork  on  the  vertex, 
enables  the  patient  to  thus  hear  the  note  better  in  cases  of  middle  or 
external  ear  disease  than  when  the  nerve  is  aiFected.  The  disease  of 
the  middle  ear  is,  perhaps,  sometimes  of  a  dystrophic  sort. 

Many  tabetics  are  troubled  with  tinnitus  and  vague  subjective  audi- 
tory sounds.  Others  have  constant  or  paroxysmal  attacks  of  aural 
vertigo  that  may  be  sufficiently  severe  to  provoke  vomiting  and  great 
prostration.  Auditory  hyper  excitability  to  electric  currents  was  found  by 
Marina  ^  in  eight  out  of  eleven  cases  of  tabes,  which  also  indicates  the 
frequency  of  disturbance  of  the  auditory  apparatus  in  locomotor  ataxia. 
Bounnier  ^  attributes  to  labyrinthine  disturbance  many  of  the  common 
signs  and  symptoms  of  the  disease.  He  enumerates  deafness,  vertigo, 
ataxia,  nystagmus,  diverse  disturbances  of  oculoraotricity,  pupillary 
changes,  and  a  large  number  of  others,  and  found  labyrinthine  irregu- 
larity in  80  per  cent,  of  cases  examined. 

The  senses  of  smell  and  of  taste  have  also  been  found  impaired  in  rare 
cases,  even  to  the  point  of  complete  loss.  A  careful  examination  for 
similar  defects  in  all  cases  would  probably  show  them  to  be  somewhat 
common.  Klippel  and  Julian  ^  have  reported  nasal  crises  marked  by 
curious  sensations  in  the  nose  and  nasopharynx  and  violent  bouts  of 
sneezing. 

Visceral  Disorders. — The  visceral  features  of  tabes  are  among:  the 
most  interesting  and  constant  manifestations  of  the  disease,  and  among 
those  most  frequently  overlooked  and  misinterpreted  by  the  physician. 
They  consist,  for  the  most  part,  of  paroxysmal  attacks  attended  by  pain 
and  disturbed  function  of  some  viscus,  as  the  stomach,  intestine,  or 
bladder,  and  are  called  tabetic  crises.  Other  visceral  disorders  are  of  a 
continuous  character,  and  are  attributable  to  impairment  of  the  nervous 
and  vasomotor  control  of  the  parts.  Though  any  viscus  may  be  affected 
in  tabes,  the  crisis  features  for  the  given  patient  are  usually  limited  and 
uniform  in  their  manifestations. 

The  Stomach. —  Gastric  crises  in  tabes  are  very  common.  They 
are  characterized  essentially  by  pains  and  vomiting.  The  pains  are 
located  in  the  pit  of  the  stomach  and  often  radiate  in  various  directions. 
They  are  occasionally  referred  to  the  heart;  indeed,  angina  pectoris 
may  appear  with  them.  They  are  intense,  and  sometimes  so  severe  as 
to  seem  unbearable,  and  may  actually  cause  insensibility.  Sometimes 
they  strike  through  to  the  back  or  flash  into  the  flanks  and  through  the 
abdomen.  The  vomiting  is  repeated  and  intractable.  Sometimes  it  is 
attended  with  excessive  straining,  and  again  the  gastric  contents  are 
ejected  with  very  slight  eructative  efforts.  The  vomitus  at  first  consists 
of  undigested  food  and  then  of  gastric  mucus  in  large  amounts,  and 
finally  of  bilious  mucus  in  the  protracted  attacks.  The  vomiting  is  fre- 
quently repeated,  only  a  small  amount  being  ejected  at  a  time  after  the 
first  efforts.  The  slightest  ingestion  of  food  or  liquid  of  any  sort 
promptly  provokes  a  repetition  of  the  emesis.     Sahli,  Hoffmann,  and 

1  "  Archiv.  f.  Psych.,"  t.  xxi,  p.  156.         ^  u  Nquv.  Icon,  de  la  Salpet.,"  1899. 
2  "Eev.  de  Med.,"  Jul.  10,  1900. 


428  DISEASES  OF  THE  CORD  PROPER. 

others  have  shown  that  there  is  hyperacidity  due  to  an  increase  of 
hydrochloric  and  lactic  acids,  most  marked  at  the  beginning  of  the 
attack  and  gradually  diminishing  as  it  proceeds. 

The  gastric  crisis  is  usually  attended  by  a  state  of  marked  prosli'cu- 
tion  that  may  even  recall  the  collapse  of  the  algid  stage  of  cholera  and 
is  usually  equal  to  that  of  severe  seasickness.  The  patient,  cold, 
blanched,  and  covered  with  profuse  perspiration,  presents  the  appear- 
ance of  severe  shock. 

Gastric  crises,  like  all  the  critical  manifestations  of  tabes,  are  of 
sudden  onset  and  abrupt  termination.  They  may  last  an  hour  or  t^^'0,  or 
several  days  or  weeks  without  intermission.  In  spite  of  the  great 
thirst  that  attends  prolonged  attacks,  the  smallest  amount  of  liquid  is 
not  tolerated  by  the  stomach,  and  alimentation  per  os  is  out  of  the 
question.  Suddenly  the  patient  may  feel  hungry,  the  pains  may 
abruptly  cease,  and  both  food  and  drink  may  be  taken  freely  without 
further  disturbance. 

Gastric  attacks  often  occur  in  the  preataxic  stage  of  posterior 
sclerosis  and  are  attributed  to  all  sorts  of  indigestion,  but  it  is  difficult 
to  identify  any  actually  determining  cause.  They  sometimes  occur  but 
once  in  a  given  case.  Ordinarily,  they  are  repeated,  and  sometimes  with 
regularity,  every  few  weeks  or  months,  or  even  daily.  After  several 
years  they  may  diminish  in  frequency  and  definitely  cease,  or  they 
may  persist  throughout  the  entire  course  of  the  disease.  They  may 
even  cause  a  fatal  termination. 

Variations  are  not  uncommonly  encountered  in  which  the  gastric 
crisis  may  be  unattended  by  much  pain  or  the  pain  may  be  excessive, 
and  vomiting  slight  or  absent.  They  may  closely  simulate  hepatic  or 
nephritic  colic,  or  be  marked  most  by  the  generation  of  an  extreme 
flatulency. 

The  intestine  is  often  disturbed  in  tabes.  In  some  cases  there  is 
persistent  causeless  diarrhea,  marked  by  frequent  slight  liquid  stools,  not 
attended  by  colics  or  pain.  In  other  instances  constip>ation  is  beyond 
control  and  fecal  accumulations,  apparently  even  above  the  colon,  cause 
distressing  and  persistent  complaint.  Intestinal  or  rectal  tenesmus 
occasionally  drives  the  patient  almost  distracted.  There  is  a  constant 
desire  to  defecate,  but  efforts  are  abortive,  or  only  result  in  a  small 
passage.  The  repeated  imperative  character  of  these  attacks,  with  their 
apparent  causelessness,  should  serve  to  distinguish  them.  A  rectal 
examination  is  usually  negative.  In  many  late  cases  the  anal  spjkincter 
is  incompetent  to  retain  fluid  bowel-contents  or  injections. 

The  urinary  apparatus  presents  some  of  the  earliest  indications 
of  tabes.  Among  the  first  symptoms  is  a  difficulty  in  starting  the  urinary 
discharge  and  in  completely  evacuating  the  bladder.  This  condition 
must  be  intelligently  investigated,  as  it  may  escape  the  patient's  atten- 
tion or  be  deemed  of  no  significance.  As  a  rule,  tabetics  have  to  make 
forceful  abdominal  expulsive  efforts  to  complete  micturition,  and  in  some 
cases  this  is  aided  by  pressing  the  hands  deeply  into  the  lower  belly- 
wall.  Not  infrequently  after  protracted  waiting,  the  feeble  stream  sud- 
denly ceases  to  flow,  or  after  the  act  is  thought  to  be  completed  a  small 


DISEASES  OF  THE  WHITE  MATTER  OF  THE  CORD.  429 

ainouiit  of  urine  wets  tlie  clothing.  Complete  reteyitlon  is  rarely 
encountered,  but  daily  catheterization  may  be  required  in  some  cases. 
Similarly  partial  or  complete  incontinence  is  met  with,  l)ut  what  is  more 
common  is  an  inability  to  control  the  flow  of  a  few  drops  or  more  of  urine 
if  the  slightest  desire  to  urinate  arises,  or  even  the  thought  of  it  occur. 
Very  frequent  urination  may  be  due  to  a  weak  sphincter  or  to  cystitis, 
which  often  arises  from  retention. 

The  character  of  the  urine  in  tabes  is  frequently  altered.  Glycosuria 
is  somewhat  common  among  tabetics.  The  hereditary  relation  of  tabes 
and  diabetes  has  been  already  suggested.  The  medullary  lesions  of 
tabes  may  stand  for  something  in  this  relation.  In  some  cases  there  is 
a  quantitative  diminution  of  the  urea,  or  phosphates,  or  chlorids.  Some- 
times the  quantity  of  urine  is  notably  lessened,  sometimes  greatly  in- 
creased in  a  paroxysmal  manner. 

The  mucous  lining  of  the  urethra  and  the  bladder  may  be  insensitive, 
but  that  does  not  prevent  their  being  the  seat  of  atrocious  painful 
attacks  that  constitute  vesical  crises,  or,  extending  to  the  lumbar  regions, 
suggest  the  term  nephritic  crises.  During  such  attacks  the  patient  is 
constantly  tormented  with  the  desire  to  urinate,  but  fails  to  express 
more  than  a  drop  or  two  at  a  time.  Meantime  the  colicky,  darting, 
intense  pains  about  the  neck  of  the  bladder  and  down  the  urethra  or 
thighs  may  give  rise  to  intense  suifering.  Lightning  pains  in  this  region 
are  not  infrequent  and  vesical  and  rectal  crises  are  often  associated. 

The  generative  functions  frequently  undergo  modifications  in 
tabes.  In  over  one-half  the  cases  there  is  a  loss  of  sexual  appetite  and 
more  or  less  impotence.  Erections  either  completely  default  or  are  par- 
tial, and  ejaculation  does  not  take  place.  Impotence  may  develop  very 
early,  and  sometimes  is  the  first  symptom  to  attract  the  patient's  notice. 
In  a  majority  of  these  cases  there  is  an  early  genital  excitement  that  has 
sometimes  led  to  sexual  excesses  and  has  perhaps  contributed  to  the 
idea  of  the  causal  role  of  such  practices.  The  same  thing  is  seen  in 
general  paresis.  Other  reflexes  than  the  genital  may  be  exaggerated  in 
the  initial  period  of  tabes,  as  witness  the  increased  knee-jerk  that 
appears  in  very  exceptional  instances,  and  the  spasmodic  action  of  the 
bowels,  rectum,  and  bladder. 

With  the  loss  of  generative  aptitudes  in  tabes  we  usually  find  a 
diminution  or  complete  extinction  of  the  cremasteric  reflex.  As  there 
is  a  loss  of  appetite  these  patients  make  no  complaints,  contrasting 
sharply  with  the  sexual  neurasthenic,  whose  cremaster  also  is  likely 
to  be  extremely  active.  In  the  same  tabetic  condition  the  bulbocavernous 
reflex  of  Onanoif,  or  the  virile  reflex,  as  it  is  called  by  Hughes,  is 
usually,  if  not  always,  absent.  To  secure  this  reflex  the  index-finger 
of  the  examiner  is  firmly  placed  over  the  bulbar  portion  of  the  urethra 
at  the  angle  of  the  scrotum  and  perineum,  and  the  mucous  membrane  of 
the  corona  glandis  lightly  pinched.  The  palpating  finger  will  distin- 
guish the  contractions  of  the  bulbocavernous  and  ischiocavernous  mus- 
cles. This  reflex  is  said  to  be  invariably  present  in  healthy  males, 
and  even  in  other  nervous  diseases,  whenever  complete  erection  is 
possible. 


430  DISEASES  OF  THE  COED  PROPER. 

Testicular  analgesia  has  been  already  mentioned.  It  is  present  in 
about  four-fifths  of  all  tabetics,  and  is  not  infrequently  attended  by 
atrophy  of  the  testicle. 

In  female  tabetics  there  are  analogous  changes  in  the  sexual  sphere. 
In  both  sexes  the  genital  organs  are  occasionally  the  site  of  painful 
crises  that  are  commonly  misunderstood,  especially  as  they  are  prone  to 
occur  in  the  preataxic  stage  of  the  disease. 

The  Respiratory  Apparatus. — Hyperesthesia  and  anesthesia  of  the 
soft  palate  and  diminution  or  increase  of  pharyngeal  and  lar^mgeal  sen- 
sibility may  be  found  separately  or  variously  combined  in  cases  of  loco- 
motor ataxia.  Oppenheim  has  described  pharyngeal  crises,  consisting 
of  rapidly  repeated,  noisy,  and  very  painful  swallowing  efforts  that  are 
involuntary.  They  last  from  a  few  minutes  to  a  half-hour  and  are  at- 
tended by  some  facial  cyanosis  and  abundant  perspiration.  The  writer 
has  observed  them  in  a  case  with  progressive  involvement  of  the  cranial 
nuclei. 

Laryngeal  crises  are  tolerably  common  in  tabes  and  vary  greatly  in 
degree  and  intensity  in  different  cases.  Sometimes  there  is  a  noisy, 
croupy  inspiration,  to  which  a  cough  may  be  added  that  strongly  sug- 
gests whooping-cough.  There  is  more  or  less  dyspnea,  pain,  anxiety, 
and  depression.  In  some  instances  the  dyspnea  seems  to  be  absolute 
and  the  patient  falls  suddenly,  cyanotic,  unconscious,  and  convulsed. 
After  a  few  moments  the  laryngeal  spasm  yields  and  full  consciousness 
immediately  returns.  This  form  of  laryngeal  crisis  has  been  called  the 
laryngeal  stroke  by  Charcot. 

In  patients  subject  to  these  crises  they  may  be  provoked  by  slight 
irritation  of  the  laryngeal  mucous  membrane  by  mechanical  or  other 
means,  and  in  some  instances  by  pressure  of  a  sensitive  point  on  the 
side  of  the  neck  between  the  lower  border  of  the  larynx  and  the  sterno- 
mastoid.  Like  other  tabetic  crises,  they  may  increase  in  severity  and 
frecjuency  or  grow  less  intense  as  time  passes,  and  they  have  the  same 
tendency  to  recur.  Though  giving  rise  to  alarming  symptoms,  they  are, 
ordinarily,  without  danger  in  themselves.  They  appear  to  be  due  to 
unusual  sensitiveness  of  the  laryngeal  surfaces. 

Laryngeal  palsies  are  encountered  in  tabes  and  may  or  may  not  be 
attended  by  larjmgeal  crises.  The  palsy  may  affect  any  of  the  laryn- 
geal groups  of  muscles  on  one  or  both  sides,  but  seems  to  exercise  a 
preference  for  the  dilators.  Corresponding  respiratory  and  vocal  symp- 
toms follow.  The  nerves,  roots,  and  bulbar  centers  have  been  found 
variously  degenerated,  and  the  muscles  themselves  secondarily  atrophied. 
Bronchial  attacJcs,  marked  by  spasmodic  cough  and  respiratory  difficulty, 
are  rarely  encountered. 

The  Vascular  Apparatus. — Taking  into  view  the  fact  that  syph- 
ilis is  one  of  the  commonest  causes  of  vascular  deformities  and  disease, 
the  frequency  of  arterial  sclerosis  and  cardiac  abnormalities  in  loco- 
motor ataxia  is  not  surprising.  Aside  from  the  cerebral  vascular  acci- 
dents arising  from  this  source,  angina  pectoris,  associated  sometimes  with 
gastric  crises,  is  encountered.  Valvular  disease,  affecting  both  the  mitral 
apparatus,  usually  in  the  form  of  insufficiency,  and  the  aortic  valve, 


DISEASES  OF  THE  WHITE  MATTER  OF  THE  COED.  431 

raainly  by  stenosis,  is  found  with  considerable  frequency.  In  300  cases 
Limbacli  ^  found  mitral  insufficiency  alone  in  2  cases;  with  aortic 
stenosis  once ;  2  cases  of  aortic  insufficiency  were  noted^  1  of  aortic 
insufficiency  and  stenosis,  and  1  aneurysm  of  the  aorta, — 7  in  all,  and 
all  syphilitic.      A  rapid  pulse,  from  100  to  120,  is  not  uncommon. 

The  temperature  in  tabes  is  normal  or  only  shows  varia- 
tions dependent  upon  intercurrent  associated  or  secondary  disor- 
ders. Pel  2  has  reported  a  case  with  crises  of  high  temperature 
and  rapid  pulse  lasting  about  twenty-four  hours.  Tliere  were  also 
coryza,  lacrymation,  photophobia,  and  lancinating  pains  in  the  face 
and  eyes. 

Trophic  Disorders. — The  disturbance  of  nutrition  in  tabes  finds 
some  manifestation  in  nearly  every  case,  and  there  is  no  tissue  or  struc- 
ture that  may  not  be  affected.  The  great  majority  of  tabetics,  and 
perhaps  all  in  the  later  stages,  show  a  depravity  of  the  general  nutrition 
that  can  not  be  explained  by  their  physical  inactivity,  by  pains,  or  by  a 
syphilitic  cachexia.  In  the  preataxic  and  ataxic  stages  the  general 
malnutrition  is  frequently  well  marked,  but  exceptionally  the  tabetic  is 
plump,  ruddy,  and  apparently  vigorous. 

Osseous  System. — On  the  part  of  the  skeleton  tabetic  dystrophy 
presents  two  striking  clinical  manifestations, — spontaneous  fractures  and 
dystrophic  arthropathies. 

Spontaneous  fractures  in  tabes  are  more  frequent  than  might  be 
supposed,  as  they  are  not  by  any  means  always  referred  to  their  proper 
origin.  It  would  appear  that  they  are  more  common  among  women 
than  in  men.  They  may  occur  in  the  very  early  stages  of  posterior 
sclerosis,  during  the  ataxic  stage,  or  in  the  last  phase  of  the  disease. 
Their  most  frequent  site  is  the  femur,  especially  the  shaft ;  the  leg  bones, 
and  those  of  the  forearm  ;  but  any  long  bone  may  present  this  accident, 
and  even  the  vertebral  bodies  are  sometimes  thus  affected.  The  fractures 
may  be  repeated  or  multiple  in  the  same  subject.  Separations  of 
epiphyses  and  of  the  bony  insertions  of  muscles  are  also  encountered. 

Tabetic  fractures  are  marked  by  the  practical  absence  of  pain  in  the 
affected  part,  and  by  the  usually  insignificant  force  that  occasions  them. 
They  have  followed  merely  the  crossing  of  the  knees  or  have  taken 
place  while  the  patients  have  been  calmly  walking  on  a  smooth  surface. 
Union  takes  place  readily,  but,  owing  to  the  lack  of  pain,  which  ordi- 
narily reinforces  the  immobilization  of  the  parts  by  splints,  movements 
of  the  limb  are  not  inhibited.  Shortening  and  extensive  callus  are  the 
natural  results. 

The  bones  in  tabes  and  paretic  dementia  present  a  cerimn  fragility 
which  lays  them  liable  to  fracture  during  life.  To  the  naked  eye  they 
often  present  a  porosity  and  a  shrinking  of  the  compact  substance,  with 
an  increased  sponginess  of  the  more  open  structures  and  sometimes  an 
enlargement  of  the  medullary  canal.  Microscopically,  the  Haversian 
canals  are  dilated  and  some  decalcification  is  evident.  The  osteoblasts 
are  shrunken  and  sometimes  show  fatty  degeneration,  while  the  medul- 
lary substance  is  increased  to  an  amount  corresponding  to  the  diminished 

1  "Deutsch.  Zeit.  f.  Nervenheilk.,"  1895.      ^  "  Berlin,  med.  V^och.,"  Juii.  26,  1899. 


432 


DISEASES  OF  THE  COED  PROPER. 


osteal  portion.  This  results  in  an  inversion  of  the  ordinary  ratio 
between  the  organic  and  inorganic  elements.  Normal  bones  are  about 
two-thirds  inorganic  substance ;  tabetic  bones  are  about  two-thirds 
orc/aniG  matter.  In  other  words,  these  bones  present  a  rarefying  osteitis. 
By  some  this  is  attributed  to  changes  in  the  nutrient  artery  and  nerve, 
which  have  been  found  sclerotic  and  neuritic.  For  others  tlie  lesion  is 
a  manifestation  of  the  trophic  disturbance  arising  from  modification  of 
trophic  cells  in  the  spinal  ganglia  and  cord. 


Fig.  192.— Spontaneous  fractures  and  arthropathic  disintegrations  (Charcot). 

Tabetic  Arthropathy. — One  of  the  early  features  of  tabes  is  an 
abnormal  range  of  joint-motion.  This  may  be  observed  even  in  the  pre- 
ataxic  stage,  but  is  usually  developed  after  incoordination  has  appeared. 
Putnam  i  was  among  the  first  to  call  attention  to  the  fact  that  the  joints 
in  tabetics  could  be  forced  into  extreme  flexion  or  extension  without 
producing  much  or  any  pain,  and  attributed  the  fact  to  analgesia. 
Frankel  and  Faure,  ^  in  a  fuller  study  of  the  matter,  show  the  extreme 
range  of  motion  that  is  customarily  found  in  the  joints  in  this  disease. 
They  found  that  in  locomotor  ataxics  the  foot,  wrist,  elbows,  and  fingers 
1  ' '  Best.  M.  and  S.  Jour. , ' '  Aug.  29,  1895.       ^  < <  Xouv.  Icon,  de  la  Saltpet. , ' '  July,  1896. 


DISEASES  OF  THE  WHITE  3IATTER  OF  THE  CORD. 


43: 


are  similarly  aifected.  Their  patients  could  execute  at  the  first  attemjDt 
the  "  split "  attitude  that  acrobats  only  attain  by  years  of  practice.  They 
attribute  this  abnormal  flexibility  to  muscular  and  joint  analgesia  in 
part,  but  principally  to  a  loss  of  the  muscular  tone.  This  condition  of 
the  joints  places  them  at  a  certain  disadvantage,  so  that  the  joint-surfaces 
are  not  properly  coapted  and  ligamentous  stretching  is  often  induced. 
Taken  with  the  incoordination  of  movement,  there  is  little  doubt  that 
the  joints  are  subjected  to  unusual  traumatic  tvvistings  and  shocks.  In 
addition,  there  is  present  the  trophic  disturbance  marked  by  fragility 
of  bones,  and  out  of  it  all  arises  the  iahetic  or  Charcot^s  joint.  Its 
frequency  in  syringomyelia  adds  force  to  the  belief  that  the  spinal  lesion 
is  the  principal  cause,  the  traumatism  the  excitant. 


Fig.  193.— Tabetic  arthropathy  of  the  left  knee. 


A  tabetic  arthropathy  is  marked  at  first  by  (1)  rapid  or  even  sudden 
onset,  (2)  entire  or  nearly  entire  absence  of  pjain  and  tenderness,  and  (3) 
enormous  swelling  of  the  adjoining  parts.  The  patient,  while  walking  or 
using  a  member,  may  notice  a  sharp  cracking  in  a  joint  and  find  that  the 
limb  feels  heavy  and  more  unmanageable  than  usual.  Shortly — that  is, 
in  the  course  of  a  few  days — not  only  the  joint,  but  the  entire  segment 
of  the  limb  is  greatly  swollen.  This  swelling  may  be  the  first  thing  to 
attract  attention.  The  parts  are  found  tense  but  cool,  and  devoid  of 
redness  and  tenderness.  The  swelling  is  extreme,  but  not  boggy,  and 
-does  not  pit  on  pressure.  Movements  of  the  joint  and  its  employment 
28 


434 


DISEASES  OF  THE  COED  PROPER. 


in  no  way  inconvenience  the  patient.  In  favorable  cases,  after  a  little 
time,  the  swelling  subsides  and  all  trouble  disappears  except  a  little 
thickening  about  the  joint  and  some  creaking  in  the  articulation.  There 
is,  however,  a  great  tendency  to  the  recurrence  of  aggravated  and  more 
lasting  attacks.  In  severe  cases  the  swelling  does  not  disappear  so 
promptly,  but  becomes  circumscribed  about  the  joint  in  a  more  or  less 
globular  form,  and  the  joint-surfaces  as  well  as  the  ligamentous  struc- 
tures undergo  disintegration.  Finally,  the  limb-segments  may  be  united 
only  by  soft  tissues  tliat  permit  painless  motion  and  circumduction  in  every 
direction.  Added  to  the  joint-changes,  we  may  have  spontaneous  frac- 
tures, epiphyseal  separations,  suppuration,  and  even  the  protrusion  of  the 
bones  through  the  skin.  Old  tabetic  joints  present  merely  a  bag  of 
bone-fragments  where  articulations  were  formerly  located. 

In    132  cases  of   tabetic  joint   disease  Kredel    found  arthropathies 
occurring  21  times  in  the  prodromic  or  preataxic  stage,  38  times  between 


Fig  194. — Tabetic  arthropathy  of  right  knee,  early  stage,  with  edema  of  the  entire  extremity  (Souques 

and  J.  B.  Charcot). 

the  first  and  fifth  year  of  the  disease,  32  times  from  the  fifth  to  the 
tenth  year,  and  41  times  after  the  tenth  year.  They  occur  in  3  or  4 
per  cent,  of  all  cases,  and  more  frequently  in  women  than  in  men.  - 

The  localization  of  joint-disease  in  tabes  is  mainly  in  the  large  joints, 
but  no  articulation  is  exempt.  Flatow  collected  139  cases,  in  41  of 
which  there  were  bilateral  arthropathies.  The  order  of  frequency  was  as 
follows  :  knee,  60  ;  foot,  39  ;  hip,  38  ;  shoulder,  27  ;  elbow,  hand, 
fingers,  and  maxilla,  4  to  6  times  each. 

Upon  section  of  these  joints  the  capsules  are  found  dilated,  often 
ruptured,  and  in  old  cases  completely  destroyed.  The  ligaments,  espe- 
cially those  within  the  joints,  as  at  the  knee  and  hip,  are  diseased  or 
have  disappeared.  The  synovial  membrane  is  thick,  rough,  and  often 
adherent  to  the  surrounding  parts ;  later  it  may  be  absent.     It  may 


DISEASES  OF  THE  WHITE  MATTER  OF  THE  CORD.  435 

contain  bony  particles  and  osseous  nodules.  The  joint-fluid  is  thin  and 
clear  or  yellowish  and  exceptionally  purulent  or  bloody.  At  first  it  is 
abundant  and  infiltrates  the  parts  about  the  joint,  into  which  it  escapes 
through  the  ruptured  capsule  and  accounts  in  some  cases  for  the  great 
swelling  in  the  limb.  It  may  contain  floating  bodies  in  large  number, 
bony  particles,  and  detritus. 

The  ends  of  the  bo7ies  and  joint-surfaces  may  be  either  (1)  eroded, 
as  is  most  usual,  and  greatly  reduced  in  all  their  dimensions,  even  ta 
the  complete  destruction  of  several  inches  of  their  length,  or  (2)  may 
present  the  hypertrophic  exaggeration  of  an  arthritis  deformans.  These 
two  types  may  be  combined  in  the  same  joint.  The  rule  is  that  the 
hypertrophic  form  occurs  in  the  knee,  the  atrophic  variety  at  the  hip 
and  shoulder.  The  disintegration  of  the  joint  may  be  increased  by 
intracapsular  fractures  or  by  fragmentation  of  the  eroded  shafts  and 
separated  epi])hyses. 

Juergens  has  found  that  in  most  tabetics  nearly  all  the  joints  show 
capsular  enlargement,  elongation  of  ligaments,  vascular  dilatation,  and 
some  synovial  roughening.     The  preponderance  of  such  joint-disease  in 


Fig.  195.— Tabetic  feet.    1  and  3  show  deformity  due  to  arthropathie  disintegration  of  tlie  tarsus;  2  has  a 
perforating  ulcer  under  head  of  first  metatarsal. 

the  lower  extremities  depends,  perhaps,  upon  their  more  exacting  and 
vigorous  use,  and  consequent  liability  to  strains  and  traumatism  and 
upon  the  major  lesions  of  the  lumbar  cord. 

Trophic  Cutaneous  Disorders. — In  tabes  there  are  a  number  of 
trophic  dermatoses  that  are  of  rare  occurrence  and  insignificant  import- 
ance. Herpes  zoster  is  of  more  frequent  appearance,  and  finds  its  fav- 
orite location  on  the  trunk,  rarely  in  the  distribution  of  the  trifaciaL 
The  epidermis  of  the  extremities,  especially  the  upper  ones,  is  sometimes 
hypertrophic.  Hyperidi^osis,  anidrosis,  and  the  loss  of  nails  or  teeth 
have  been  occasionally  noted. 

Perforating  ulcer  is  not  an  uncommon  accident  in  tabes,  and,  though 
painless,  is  of  considerable  importance.  It  is  usually  situated  in 
the  foot,  but  may  occur  in  the  hand,  and  some  authors  have  conceived 
that  maxillary  and  even  cardiac  and  visceral  ulcerations  were  in  some 
instances  of  the  same  character.  It  usually  begins  as  a  callus  or  corn 
on  the  sole  of  the  foot,  under  the  ball  or  under  the  base  of  the  fifth 
metatarsal,  or  at  the  heel.  Ulceration  follows,  and,  if  neglected,  may 
denude  bone  and  lead  to  exfoliation.      The  ulcer  is  indolent,  persistent. 


436  DISEASES  OF  THE  COED  PROPER. 

and  refractory  to  any  treatment  if  pressure  be  not  removed.  Not  un- 
commonly the  toe-joints  or  those  of  the  foot  present  dystrophic  condi- 
tions at  the  same  time.  Bedsores  only  appear  in  terminal  stages,  and 
present  nothing  of  a  special  nature.  After  an  attack  of  lightning  pains 
the  part  in  which  they  are  principally  located  may  sometimes  present  a 
more  or  less  distinct  ecchymosis. 

Muscular  Atrophies. — In  addition  to  the  invariably  diminished 
muscular  tone  that  has  already  been  mentioned,  and  the  rare  occurrence 
of  fracture  of  a  tendon,  some  tabetic  cases  present  notable  amyotrophia. 
This  should  be  sharply  distinguished  from  the  emaciation,  flaccidity,  and 
incoordinate  feebleness  that  are  very  common  in  advanced  tabes.  As 
a  rule,  the  muscular  masses  and  contours  are  well  preserved  until  the 
ataxia  is  well  developed,  and  often  until  the  patient  has  for  long  been 
unable  to  walk,  but  in  rare  cases,  perhaps  in  one  per  cent.,  localized 
muscular  atrophy  appears.  Its  common  seat  is  in  the  lower  extremities, 
especially  invading  the  foot-  and  leg-muscles,  and  is  usually  bilateral. 
The  upper  extremities  may  be  invaded,  particularly  the  small  muscles 
of  the  hands,  or  even  the  forearm,  arm,  and  shoulder.  The  cranial 
nerves  are  sometimes  similarly  aifected.  The  motor  portion  of  the 
trifacial  and  the  hypoglossus  are  the  ones  usually  selected. 

The  onset  of  such  amyotrophies  is  usually  insidious.  They  present 
variously  modified  electrical  reactions,  the  full  reaction  of  degeneration 
being  rare.  Once  established,  the  muscular  atrophy  of  tabes  remains 
fixed,  and  does  not  invade  group  after  group  of  muscles,  as  do  various 
progressive  amyotrophies.  The  resulting  deformity  in  the  foot  is  due 
to  pure,  flaccid  atony  without  contracture.  The  foot  drops  by  its  own 
weight  and  the  pressure  of  bed-covering  into  an  equinovarus.  In  the 
hands  some  clawing  may  be  induced  and  the  thenar  eminence  is  likely  to 
disappear.    Hemiatrophy  of  the  tongue  follows  hypoglossal  involvement. 

In  a  general  way,  according  to  Marie,  tabetic  muscular  atrophies 
may  be  divided  into  two  groups  :  (1)  Those  appearing  at  an  advanced 
period  of  the  disease,  presenting  a  symmetrical  distribution,  rarely 
marked  by  fibrillary  twitchings  ;  (2)  those  occurring  often  in  the  earlier 
stages  of  the  disease,  usually  unilateral  in  distribution,  and  marked  by 
fibrillary  contractures  and  sometimes  by  the  reaction  of  degeneration. 
The  first  group  embraces  those  atrophies  confined  to  the  distal  portions 
of  the  lower  or  upper  extremities,  and  recalls  the  conditions  found  in 
multiple  neuritis.  The  second  group  contains  lingual  hemiatrophy, 
localized  atrophies  of  the  shoulder,  of  the  back,  of  the  hand,  and  one- 
sided involvement  of  cranial  nerves.  They  are  analogous  to  lesions  of 
the  nuclear  gray  matter.  Both  the  central  and  peripheral  lesions  are 
found,  and  in  the  associations  above  indicated.  The  wasted  muscles 
present  the  usual  histological  change,  due  to  degeneration  in  the  lower 
motor  neuron. 

Cerebral  Disturbances. — In  addition  to  the  vascular  cerebral  acci- 
dents, with  resultant  palsies  and  the  involvement  of  cranial  nuclei, 
tabetics  are  subject  to  other  cerebral  disorders.  These  embrace  the  m.any 
possibilities  of  cerebral  syphilis,  and  particularly  paretic  dementia. 
Apoplectiform  and  epileptiform  attacks,  or  any  unusual  forgetful ness, 


DISEASES  OF  THE  WHITE  MATTER  OF  THE  CORD.  437 

exhilaration,  expansiveness,  or  stupor  should  at  once  arouse  suspicion  of 
this  fatal  cerebral  disorder.  It  should  be  studied  in  this  connection, 
and  is  set  forth  in  the  second  part  of  this  work.  On  the  whole,  nota- 
ble psychical  disturbance  is  a  rarity,  but  some  degree  of  apathv,  of  in- 
difference, is  usually  to  be  observed.  This  pertains  particularlv  to 
themselves,  their  disease,  their  almost  hopeless  prospects.  It  is  not 
much  modified,  even  by  the  most  atrocious  suffering,  and  persists  even 
in  the  stage  of  complete  helplessness.  Tabetics,  however,  often  mani- 
fest large  mental  activities  and  retain  their  business  capacity  to  the  end. 

Tabulation  of  Tabetic  Symptoms. — The  following  table  of  tabetic 
symptomatology  is  that  of  Limbach,^  based  upon  400  cases  selected 
from  the  private  practice  of  Professor  Erb. 

In  the  first  table  the  usual  early  symptoms  are  arranged  in  their  order 
of  frequency.  There  is  an  overlapping,  as  frequently  two  or  more  are 
alleged  to  have  come  on  at  or  about  the  same  time  : 

Early  Symptoms  of  Tabes. 

First  Second 

Symptom.  Symptom.  Total. 

Lancinating  pains 283  times  65  times  348  times. 

Cystic  weakness  .    .  _. 90     ^'  119     "  209     " 

Feeling  of  weakness  in  legs  ....    78     "  113     "  191     " 

Paresthesia  in  less 74     "  10     "  84     " 

Girdle  sensation      34     "  44     "  78     " 

The  relative  frequency  of  various  objective  and  subjective  symptoms 
as  observed  in  these  400  more  or  less  complete  histories  is  shown  in  the 
following  table  : 

Relative  Freqltency  or  Tabetic  Symptoms. 

Per  cent, 

1    f  (a)  Failure  of  knee-jerk  and  Achilles  jerk 92.0    ),  q/.  9- 

I  {h)  Alteration  in  these  reflexes 4.25  j'' 

2.  Swaying  with  eyes  closed 88.75 

3.  Lightning  pains 88.25 

4.  Disturbances  of  the  bladder 80. 5 

5.  Ataxia  of  the  lower  extremities 74.75 

6.  Changes  in  the  pupillary  reactions 70.25 

7.  Paresthesia  of  lower  extremities 64. 5 

8.  Feeling  of  weakness  in  the  legs 62.25 

9.  Diminution  or  disappearance  of  sexual  desire 58.25 

10.  Alterations  in  size  of  pupils 48.25 

11.  Delayed  conduction  of  pain -. 36.5 

12.  Slight  analgesia  of  lower  extremities 33.75 

13.  Girdle  sensation 31.0 

14.  Transitory  double  vision 26.5 

15.  Diminution  of  sense  of  touch  on  lower  extremities 23.25 

16.  Paresthesia  in  ulnar  distribution 16.5 

17.  Ocular  paralyses  and  ptosis 16.0 

18.  Optic  atrophy 6.75 

19.  Persistence  of  painful  impression  in  the  legs 6.0 

20.  Various  crises 5.25 

21.  Arthropathies      1.75 

Course  and  Varieties. — Ordinarily  speaking,  the  onset  of  tabes  is 
extremely  insidious  and  its  course  very  slowly  progressive.    For  purposes 
1  "Deutsch.  Zeit.  f.  Xervenheilk.,"  1895. 


438  DISEASES  OF  THE  COED  PROPER. 

mainly  of  description  it  may  be  divided  into  the  jyreataxic,  the  ataxic, 
and  the  paralytic  stages.  These  indefinitely  blend,  and,  as  has  been 
repeatedly  indicated,  many  symptoms,  commonly  of  the  later  periods, 
may  appear  precociously  in  the  early  phases  of  the  malady.  From  the 
tabulation  of  symptoms,  as  well  as  from  their  individual  description,  it 
will  have  been  noted  that  pains  are  among  the  earliest  indications  of 
tabes,  and  these  may  persist  for  years,  even  for  a  dozen  years,  before 
the  prominence  of  other  symptoms  determines  their  character.  Usually 
only  when  visceral  crises,  vesical  weakness,  ocular  palsies,  insecurity 
upon  the  legs,  or  inability  to  walk  in  the  dark  or  down  a  stair  or  to 
stand  securely  while  washing  the  face  have  seriously  attracted  the 
patient's  attention  is  a  properly  directed  investigation  instituted. 
Then  his  "  rheumatic  pains,"  his  "  gouty  pains,"  his  "  neuralgic 
attacks,"  his  "  bilious  attacks,"  take  their  proper  place.  At  that  time 
a  search  of  the  cutaneous  sensibility  usually  reveals  its  impairment  in 
the  feet  and  legs,  the  knee-jerks  are  absent,  the  pupils  sluggish  or 
inactive  to  light,  and  the  ataxia  can  be  demonstrated  by  the  usual 
tests.  In  certain  rare  benign  cases  the  disease  never  progresses  beyond 
this  point. 

In  the  second  period  the  ataxia  increases  and  is  apparent  at  a  glance, 
but  may  be  practically  confined  to  the  lower  extremities  for  from  two 
to  six  years  or  more.  Then  it  may  invade  the  upper  extremities  pro- 
gressively. A  host  of  sensory,  motor,  trophic,  and  visceral  symptoms 
are  present,  varying  in  every  case  but  usually  consistent  and  uniform 
in  the  given  instance.  Even  at  this  point  the  disease  may  halt  in  its 
progressive  course.  Usually  the  lack  of  motor  control  becomes  greater 
and  greater,  walking  more  and  more  laborious,  the  ataxia  intensified, 
and  finally  the  patient  is  brought  to  the  bed  or  chair  in  the  third 
period  of  the  disease.  Xow  accentuation  of  intestinal  and  especially  of 
vesical  disturbance  and  the  depreciation  of  the  general  physical  state, 
taken  with  the  helplessness,  make  the  picture  pitiful  indeed.  All  its 
colors  may  be  deepened  by  the  atrocious  pains  that  sometimes  pursue 
the  unhappy  victim  to  the  last.  Cystitis  looms  as  a  constant  menace 
to  life,  and  any  intercurrent  affection  is  likely  to  be  jjromptly  fatal. 
From  ten  to  twenty  or  thirty  years  may  be  consumed  in  the  history 
of  tabes  or  it  may  unroll  its  panorama  of  symptoms  within  two  or 
three. 

Tabes  presents  numerous  variations  from  the  wide  symptom  group 
that  may  be  considered  its  common  type.  The  cervical  form  ^reaents 
pain  and  ataxia  first  in  the  upper  extremities,  which  may  also  show 
trophic  changes.  Little  static  ataxia  or  incoordination  of  locomotion 
may  be  presented.  The  knee-jerk  may  even  be  retained,  but  that  is  rare. 
In  the  bulbar  form  we  encounter  early  symptoms  on  the  part  of  the 
cranial  nerves,  pharyngeal  and  laryngeal  crises,  optic  atrophy,  and 
ocular  palsies.  The  tendency  of  ataxia  to  disappear  upon  the  appear- 
ance of  optic  atrophy  or  for  the  disease  to  then  become  stationary 
furnishes  a  definite  group  of  cases. 

From  another  view-point,  cases  may  be  considered  benign  and  grave. 
As  has  been  indicated,  the  tabetic  process  may  stop  at  almost  any  point. 


DISEASES  OF  THE  WHITE  3IATTER  OF  THE  CORD.  439 

or  after  a  lapse  of  years  may  again  slowly  advance.  Some  cases  that 
are  marked  by  intensely  painful  manifestations  seem  to  be  of  slow 
evolution.  This  may  be  a  way  of  saying  that  cases  presenting  a  pro- 
tracted first  and  second  stage,  to  which  the  lightning  pains  and  intense 
crises  are  usually  confined,  less  rapidly  disable  the  patient.  On  the 
other  hand,  cases  of  tabes  are  grave  by  the  rapidity  of  their  develop- 
ment and  the  intensity  and  generalization  of  their  symptoms,  due  to  the 
wide-spread  underlying  sclerotic  process.  Acute  cases  may  confine  the 
patient  to  bed  in  a  few  months,  Leyden  describes  cases  of  extreme 
rapidity.  Active  syphilitic  processes  in  brain  and  cord  may  be  added 
and  the  patient  at  once  overthrown.  A  marasmic  state  or  the  appear- 
ance of  paretic  dementia  constitute  conditions  of  extreme  gravity. 

Diagnosis. — The  diagnosis  of  tabes  in  the  full-blown  ataxic  stage 
rarely  presents  any  considerable  difficulty.  Confusion  usually  arises  by 
mistaking  other  diseases  for  tabes  and  in  misinterpreting  the  early 
manifestations  of  tabes  for  those  of  slighter  ailments.  Gastric,  laryn- 
geal, intestinal,  vesical,  urethral,  and  all  visceral  crises,  if  present  in  the 
preataxic  period,  are  almost  invariably  referred  to  the  wrong  source. 
Their  repetition  without  clearly  competent  exciting  cause  or  local  lesions 
should  always  arouse  suspicion  of  posterior  sclerosis,  which,  if  present, 
will  not  fail  to  present  other  symptoms  and  signs.  The  same  is  true 
of  repeated  attacks  of  severe  pains  of  a  lancinating  or  lightning-like 
character.  The  occurrence  of  these  in  a  patient  where  syphilis  is  even 
suspected  to  have  been  present  should  direct  attention  to  the  spinal  cord. 

If  the  knee-jerks  are  gone  or  very  unequal,  or  even  greatly  reduced, 
it  should  add  to  the  suspicion  of  tabes.  If,  now,  the  Robertson 
pupil  is  detected,  or  even  sluggishness  of  the  pupil  to  light  is  clearly 
made  out,  the  diagnosis  may  be  considered  established.  The  detection 
of  several  or  many  of  the  usual  subjective  and  objective  features  of  the 
disease  will  confirm  it.  Among  these,  too  much  importance  can  not  be 
given  to  vesical  disturbances  and  variations  in  the  sexual  sphere. 

The  condition  most  usually  mistaken  for  tabes  is  multiple  neuritis. 
The  differential  indications  are  tabulated  on  page  320.  Unfortunately, 
a  group  of  maladies  of  a  similar,  if  not  identical,  character  with  multi- 
ple neuritis  has  been  denominated  pseudotabes.  We  thus  encounter 
cases  described  as  toxic  pseudotabes  or  neurotabes,  due  to  alcohol,  arsenic, 
or  other  poison,  diabetic  pseudotabes,  neurasthenic  pseudotabes,  and 
syphilitic  pseudotabes.  They  often  present  the  symptoms  of  multiple 
neuritis,  with  unusually  severe  root  pains,  ocular  disturbances,  or  other 
symptoms  that  suggest  tabes.  The  absence  of  well-marked  crises,  of 
the  Robertson  pupil,  of  sphincteric  weakness,  of  pure  incoordination 
without  paresis,  and  the  history  of  the  onset  of  the  disease,  the  uniformity 
and  invariability  of  sensory  symptoms,  the  history  or  presence  of  the 
toxic  cause,  and  the  usual  early  presence  of  some  muscular  wasting  and 
the  reaction  of  degeneration  should  distinguish  pseudotabes  from  pos- 
terior sclerosis. 

Paraplegias  are  marked  usually  by  definite  areas  of  dysesthesia,  the 
reflexes  are  exaggerated,  and  clonus  common,  unless  the  cord  is  com- 
pletely divided,  when  all  motion  below  the  lesion  is  abolished.  This 
is  not  the  case  up  to  the  last  moment  in  tabes. 


440  DISEASES  OF  THE  CORD  PROPER. 

Cerebellar  tumor  may  present  some  analogy  at  first  sight,  but  usually 
we  have  choked  optic  discs,  increased  or  merely  reduced  reflexes,  intact 
sensibility,  retracted  head,  and  occipital  pain. 

Insular  sclerosis  presents  some  symptoms  found  in  tabes,  but  is  dis- 
tinguished by  the  intention  tremor,  nystagmus,  scanning  speech,  usually 
preserved  and  often  increased  knee-jerks.  The  sensory  disturbance 
and  painful  manifestations  are  insignificant. 

Syringomyelia  usually  affects  the  upper  extremities  first,  and  may  be 
mistaken  for  cervical  tabes.  The  dissociation  of  cutaneous  sensibility  is 
its  chief  characteristic,  but  even  this  has  been  found  in  tabes.  Scoliosis, 
mutilations  of  the  fingers,  local  atrophies  occurring  early  in  the  disease, 
without  incoordination  and  usually  with  increased  knee-jerks,  taken 
with  a  full  history  of  the  case  and  the  careful  delimitation  of  the  sen- 
sory disturbances,  should  make  the  diagnosis  exact. 

Prognosis. — The  diagnosis  of  tabes  largely  conveys  the  prognosis. 
When  the  degenerate  changes  that  constitute  the  so-called  sclerosis  have 
taken  place,  restitution  ad  integram  is,  as  far  as  now  known,  out  of  the 
range  of  possibilities.  While,  as  a  general  rule,  the  disease  is  a 
steadily  progressive  one,  there  are  many  exceptions.  In  the  enumeration 
of  varieties  of  tabes  attention  was  called  to  the  benign  cases  and  the 
possibility  of  the  degenerative  changes  coming  to  a  standstill  at  any 
period  of  development.  This  renders  it  the  more  difficult  to  estimate 
the  value  of  medication.  It  has  also  been  indicated  that  when  optic 
atrophy  appears  the  locomotor  difficulties  usually  do  not  increase.  The 
rate  of  advancement  of  the  disease  from  its  inception  is  some  index  of 
the  rapidity  of  its  future  progress.  Bulbar  symptoms  and  the  indica- 
tions of  developing  paretic  dementia  at  once  render  the  outlook  most 
gloomy. 

Treatment. — In  the  management  of  tabes  dorsalis  it  is  well  to  keep 
in  view  exactly  what  may  be  accomplished.  The  retardation  of  the 
disease,  or,  better  still,  its  complete  arrest,  constitutes  a  medical  victory. 
Given  the  natural  tendency  of  the  disease  to  halt  temporarily  in  occa- 
sional cases  or  to  come  to  a  permanent  standstill,  we  must  be  chary  of 
attributing  too  much  importance  to  any  line  of  medication.  The  intel- 
ligent purpose  of  treatment  is  :  (1)  To  arrest  any  active  syphilitic  process 
that  may  be  present ;  (2)  to  improve  the  general  health  ;  (3)  to  increase 
the  nutritive  condition  of  the  cord  ;  (4)  to  maintain  as  complete  muscular 
control  as  possible,  and  (5)  to  meet  the  host  of  incidental  disturbances 
as  they  arise. 

While  the  role  of  syphilis  in  tabes  is  chiefly  played  in  the  past  tense, 
it  not  rarely  happens  that  active  and  manageable  syphilitic  lesions  attend 
at  least  its  early  stages.  Meningitis,  myelitis,  neuritis,  and  cerebral  con- 
ditions or  affections  of  the  osseous  system  may  declare  themselves,  and 
yield  to  antisyphilitics.  It  is  not  a  bad  plan  to  follow  Erb  in  prescrib- 
ing an  active  antiluetic  treatment  to  clear  the  air  ;  but  it  must  be  done 
with  circumspection,  as  the  cases  are  not  infrequent  in  which  mercury 
and  the  iodids  are  not  only  not  well  borne,  but  their  use  is  productive 
of  distinct  harm.  It  is  needless  to  insist  on  this  course  of  medicine  if 
it  has  been  recently  undergone  in  a  thorough  manner,  and  it  usually  is 


DISEASES  OF  THE  WHITE  MATTER  OF  THE  COED.  441 

uncalled  for  in  the  cases  that  received  persistent,  intelligent,  and  active 
antisyphilitic  treatment  during  their  early  luetic  years.  Nevertheless  it  is 
a  good  rule  to  give  all  syphilitics  an  annual  course  of  mercury  and  iodids. 

The  general  health,  with  all  the  conditions  of  hygiene,  good  air,  and 
a  proper  diet  that  pertain  to  it,  are  worthy  of  painstaking  attention.  Not 
only  does  a  good  general  state  tend  to  retard  the  activity  of  tabes,  but 
it  protects  the  patient  from  the  great  dangers  of  intercurrent  aflfections, 
especially  of  the  acute  variety. 

The  looal  nutrition  of  the  cord  and  spinal  apparatus  may  be  improved 
by  increasing  its  blood-supply.  This  may  be  mechanically  eifected  by 
spinal  stretching.  It  is  not  desirable  to  carry  this  out,  as  first  was  done, 
by  hanging  in  the  Sayre  apparatus — ^a  proceeding  that  is  attended  by  a 
number  of  dangers.  It  can  be  effectively  accomplished  by  having,  after 
Benedict's  suggestion,  the  patient  fully  flexed  upon  himself  Tourette 
and  Chipault  ^  have  proven  that  the  lower  portion  of  the  cord  may  act- 
ually be  stretched  by  the  forward  bending  of  the  trunk.  Care  must  be 
exercised  not  to  overstretch  the  patient  at  first,  as  the  thigh-  and  back- 
muscles  may  easily  be  severely  strained.  Gradually,  in  the  course  of  a 
week  or  two,  through  daily  stances,  the  full  body  flexion,  and  conse- 
quent extension  of  the  cord,  can  usually  be  attained  without  inconveni- 
ence. The  flexed  posture  is  to  be  maintained  for  two  or  three  minutes 
only,  and  may  be  utilized  night  and  morning.  It  often  favorably  modi- 
fies the  lightning  pains,  and  sometimes  increases  the  sexual  aptitude. 
The  stretching  is  accomplished  by  seating  the  patient  on  a  low  table  or 
on  the  floor,  with  the  lower  limbs  extended.  The  head  is  then  forcibly 
depressed  toward  the  knees,  which  are  not  allowed  to  bend.  The  posi- 
tion is  to  be  maintained  not  to  exceed  two  minutes. 

Local  measures  to  the  back,  such  as  deep  massage  and  very  vigorous 
slapping,  are  of  similar  benefit  to  the  deeper  circulation.  For  this  pur- 
pose a  broad,  stout  piece  of  leather  on  a  short  handle  may  be  used  to 
vigorously  flagellate  the  back.  Its  similar  application  to  the  soles  of 
the  feet  and  on  other  paresthetic  or  analgesic  regions  is  useful.  Counter- 
irritants  along  the  spine  have  a  certain  value,  perhaps  only  an  insigni- 
ficant one.  The  best  application  is  by  the  thermocautery  of  Paquelin, 
repeated  every  seven  or  ten  days.  An  intense  white  heat  should  be 
used,  and  small  dots  quickly  and  lightly  made  at  intervals  of  an  inch  or 
two  over  the  portion  of  the  cord  principally  affected.  They  may  with 
propriety  be  extended  over  the  course  of  the  nerves  where  the  lightning 
pains  discharge.  Six,  eight,  or  ten  such  cauterizations  may  be  followed 
by  two  or  three  months'  rest,  and  then  repeated.  Cold  spinal  douches,  hot 
needle  douches,  or  steam  douches  to  the  back  are  of  comparable  utility. 

It  is  only  of  late  that  the  value  of  exercises  and  practice  to  reestab- 
lish coordination  has  been  recognized.  On  the  other  hand,  inactivity 
and  disuse  promptly  accentuate  the  loss  of  muscular  control.  The  pur- 
pose is  not  to  accomplish  feats  of  strength,  and  all  strains  and  decided 
fatigue  are  to  be  sedulously  avoided.  Patients  must  be  encouraged  to 
faithfully  and  intelligently  practise  such  movements,  motions,  and  steps 
as  are  particularly  uncertain.  In  this  way  they  may  sometimes  be 
brought  to  stand  and  to  walk  with  closed  eyes  after  static  ataxia  has 
1  "Nouv.  Icon,  de  la  Saltpetriere, "  June,  1897. 


442  DISEASES  OF  THE  COED  PROPER. 

been  well  marked,  Frankel  gives  the  following  exercises,  which  are 
of  two  classes — those  performed  in  and  those  performed  out  of  bed, 
depending  on  the  patient's  helplessness  : 

In  bed,  the  patient  is  called  upon  to  flex,  extend,  abduct,  and  adduct 
each  leg  separately  and  then  both  simultaneously.  The  knees  and  hips 
are  likewise  exercised.  The  patient  is  asked  to  place  the  heel  of  one 
foot  on  the  big  toe  of  the  other  foot.  Place  heel  upon  knee  of  the  other 
leg  and  then  slowly  travel  along  the  ridge  of  the  tibia  toward  the  ankle. 
Exercises  are  made  alternately,  first  with  one  leg,  then  with  the  other, 
with  open  and  with  closed  eyes.  These  exercises  are  attempted  over 
and  over  again,  with  frequent  rests.  Patient  is  encouraged  to  persevere 
until  he  succeeds. 

The  exercises  are  repeated  twice  a  day,  a  half  hour  in  the  morning 
and  again  a  half  hour  in  the  afternoon. 

1.  Patient  is  placed  with  his  back  to  a  chair,  heels  together,  then 
seats  himself  slowly  in  the  chair,  and  is  then  made  to  rise  in  the  same 
careful  manner.  No  cane  is  used.  If  patient  can  not  stand,  an  attend- 
ant is  placed  on  either  side  to  support  him  if  necessary. 

2.  One  leg  is  placed  at  an  ordinary  walking  step  in  front  of  the 
other,  and  then  placed  with  great  exactness  back  into  its  original  posi- 
tion. Same  exercise  is  then  performed  with  other  leg.  The  patient,  if 
necessary,  supports  himself  by  a  cane  or  otherwise. 

3.  Walks  three  paces  slowly  and  with  precision. 

4.  Rest  in  standing  position,  one  foot  before  the  other ;  with  hands 
placed  akimbo  he  flexes  his  knees  and  slowly  raises  himself  again. 

5.  Patient,  as  in  exercise  number  2,  advances  one  foot,  then  returns 
it  to  its  original  position,  and  then  places  it  one  step  behind  the  other. 
This  exercise  is  usually  a  very  difficult  one,  requiring,  as  it  does,  a  great 
deal  of  balancing  power. 

6.  Walk  twenty  steps  as  in  exercise  number  3. 

7.  Number  2  performed  without  a  cane. 

8.  Stand  without  a  cane,  with  feet  placed  together  and  hands  on  hips. 

9.  Stand  without  a  cane,  feet  separated  ;  various  movements  with 
the  arms,  grasping  objects,  forcing  back  outstretched  hand  of  physi- 
cian, etc. 

10.  Maintain  same  position  as  in  number  9,  flexing  trunk  forward, 
backward,  to  the  right,  and  to  the  left. 

1 1 .  Exercise  number  9  with  the  feet  together. 

12.  Exercise  number  10  with  feet  together. 

13.  Walk  along  a  painted  line  on  the  floor,  patient  supported  by  a 
cane. 

14.  Same  without  a  cane. 

Exercises  for  the  fingers  and  arms  are  also  employed,  based  on  the 
above-mentioned  principles. 

These  various  exercises  are  to  be  progressively  attempted  and  perse- 
vered in  as  coordinate  strength  improves.  They  may  then  be  gone  over 
again  with  closed  eyes  aided  by  a  cane  or  assistant,  then  without  aid. 
Fatigue,  however,  must  be  avoided.  In  advanced  cases  that  have  to  rely 
on  crutches,  a  tall  "  walking-frame "  or  roller-crutch,  such  as  is  used 
for  children,  may  be  employed.     This  gives  support   under  the   arms 


niSKASES  OF  THE   WHITE  MATTER  OF  THE  COED.  443 

uiul  enables  the  patient  to  exerei^e  the  leg.s.  Precise,  delicate  motions 
■with  the  lini>ers  may  also  be  developed  in  the  same  way.  The  employ- 
ment of  an  iiitelliu'ent  masseur  has  given  good  results  in  some  instances, 
as  he  can,  by  tlic  use  of"  graduated  resistive  movements,  teach  the 
patient  precision  in  the  use  of  his  legs.  The  so-called  home  bicycle 
trainer  has  also  given  some  assistance.  On  this  the  jiatient  can  pedal 
for  a  few  minutes  at  a  time,  and  the  mechanism  carries  his  feet  and  legs 
in  definite  curves. 

In  the  pre-ataxic  stage  the  patient  should  walk,  stand,  and  balance 
on  each  foot,  with  closed  eyes.  Daily  exercises  of  this  simple  character 
seem  notably  to  retard  the  appearance  of  locomotor  incoordination. 
Women  are  much  less  troubled  than  men  in  the  control  of  the  legs  and 
feet,  as  a  rule,  and  this  may  be  due  to  wearing  skirts,  which  prevents 
the  use  of  the  eyes  in  guiding  the  steps. 

Regarding  internal  medication  directed  to  the  sclerosis,  mercury, 
arsenic,  silve'r,  chlorid  of  gold,  salts  of  zinc,  strychnin,  aconitin,  atropin, 
and  a  multitude  of  others  may  be  mentioned,  but  aside  from  some  gen- 
eral tonic  properties  it  is  difficult  to  attribute  any  value  to  them.  Ergot, 
first  employed  against  a  hypothetical  chronic  inflammation  in  which  the 
sclerosis  was  supposed  to  consist,  has  proved  itself  of  some  value  in 
controlling  vesical  disturbance,  and  against  this  feature  of  tabes  may  be 
employed,  with  precautions  to  avoid  ergotism.  Charcot's  plan  was  to  use 
it  the  first  three  days  of  every  week,  or  it  may  be  used  on  alternate 
weeks  for  one  or  two  months,  then  a  long  interval  and  a  repetition.  It 
should  be  used  in  good-sized  doses  once  or  twice  a  day. 

Against  the  vesical  weakness,  especially  the  sphincteric  weakness,  the 
method  of  Brandt  to  increase  the  strength  of  the  pelvic  floor  is  of  ser- 
vice in  tabes.  The  movements  principally  useful  consist  of  having  the 
patient  separate  and  adduct  the  knees  against  resistance  from  two  to 
twenty  times  twice  daily,  at  the  same  time  vigorously  drawing  in  the 
pelvic  floor  and  body  outlets,  and  in  massage  of  the  perineal  muscles. 

For  the  ijains  of  tabes  and  the  visceral  crises  morphin  is  sometimes 
required,  but  the  physician  alone  should  administer  it,  to  prevent  the 
formation  of  a  habit,  and  then  only  as  a  last  resort.  Ice,  hot  applica- 
tions, sinapisms,  and  the  coal-tar  sedatives  should  be  first  thoroughly 
tried.  Of  the  synthetic  preparations,  phenacetin  seems  the  most  efficient. 
Blisters  and  the  cautery  to  the  painful  region  and  over  the  corresponding 
portion  of  the  cord  are  sometimes  promptly  helpful,  but  must  be  used 
with  circumspection  as  healing  is  often  faulty. 

Tabetic  Jomfe  are  best  let  alone.  Nothing  is  to  be  gained  by  cutting 
operations,  and  very  little  by  fixation  apparatus  except  such  as  enable 
the  patient  to  walk.  Perforating  idcer  is  sometimes  cured  by  stretching 
the  nerve  to  the  part. 

Cystitis  must  be  guarded  against.  If  it  develops,  it  must  be  carefully 
combated,  and  self-catheterization  may  have  to  be  taught  the  patient. 
Urotropin  in  ten-grain  doses,  twice  or  thrice  daily,  may  be  employed 
for  indefinite  periods  to  keep  the  urine  aseptic  and  prevent  cystitis. 

The  management  of  the  individual  will  often  be  found  as  difficult  as 
that  of  the  disease.  He  must  not  expect  too  much,  but  the  physician 
must  remember  that  he  is  human,  and  do  what  he  can  to  encourage  and 


444 


DISEASES  OF  THE  CORD  PROPER. 


cheer  him  in  the  face  of  his  distressing  affliction,  and  to  insure  his  faith- 
ful attention  to  the  numerous  small  and  exacting  details  of  treatment. 

The   appearance  of  any  active  syphilitic  process  demands  prompt 
recurrence  to  specific  treatment. 


COMBINED  SCLEROSES  OF  THE  SPINAL  CORD. 

Occurring,  perhaps,  as  frequently  as  tabes,  many  cases  of  or- 
ganic cord-disease  present  symptoms  referable  to  the  simultaneous  in- 
volvement of  the  lateral  and  the  posterior  columns,  which  are  found 
sclerosed  in  widely  varying  proportion.  This  condition  is  termed  ataxic 
paraplegia  by  Gowers,  progressive  spastic  ataxia  by  Dana,  and  is  known 
variously  as  jwsterolateral  sclerosis,  combined  posterior  and  lateral  scle- 
rosis, and  combined  tabes,  or  sometimes  as  spasmodic  tabes.  Some  cases 
show  a  tolerably  definite  limitation  of  the  sclerosis,  suggesting  a  sys- 
tematic degeneration,  but  usually  it  is  not  strictly  confined  to  the  physio- 
logical tracts  of  the  cord.  For  the  most  part  the  lesions  are  within 
the  posterior  half  of  the 
cord's  cross-section,  and  are 
commonly  embraced  in  the 
posterior  arterial  field  (see 
p.  332  and  Fig.  126).  Oc- 
casionally the  lesion  also  en- 
croaches upon  the  peripheral 
portion  of  the  cord  in  front, 
which  belongs  to  the  anterior 
arterial  field.  The  symptoms 
are  dominated  by  ataxia  and 
spasticity,  and  the  tendency  is 
progressively  toward  para- 
plegic helplessness. 

Etiology. — The  causes  of 

combined  sclerosis    are  numer-  ^'S-  196.— combined  posterolateral  sclerosis.   Scheme 

-P  .  showing  usual  area  of  cord-change  limited  to   the  pos- 

OUS.       it  must  be  at  once  reCOg-        terlor  arterial  field  of  the  cord  (Brissaud). 

nized  that  this  extensive  symp- 
tom group  is  frequently  a  secondary  cord-process  :  (1)  In  a  certain 
small  number  of  cases,  primarily  tabetic,  a  diifuse  myelitis  also  invades 
the  lateral  tracts ;  (2)  it  is  found  more  frequently  in  general  paresis  than 
are  lesions  entirely  confined  to  the  posterior  columns ;  (3)  a  diffuse 
myelitis  gives  rise  to  ascending  and  descending  degenerations  that  fur- 
nish a  posterolateral  sclerosis ;  (4)  leptomeningitis  may  entail  a  mar- 
ginal myelitis  that  invades  the  periphery  of  the  cord  and  principally 
affects  its  posterior  half;  (5)  vascular  lesions,  affecting  principally  the 
posterior  field,  induce  a  sclerosis  in  the  posterior  and  lateral  tracts;  (6) 
pellagra  sometimes  causes  a  combined  posterolateral  sclerosis  ;  (7)  toxic 
conditions,  as  in  the  pernicious  anemias,  may  cause  it ;  (8)  the  postero- 
lateral sclerosis  may  be  evidence  of  an  embryonic  deficiency  as  in 
Friedreich's  ataxia. 

There  is  frequently  a  history  of  antecedent  syphilis  or  one  of  expo- 


DISEASES  OF  THE  WRITE  MATTER  OF  THE  COED.  445 

sure  to  cold,  traumatism,  concussion,  or  muscular  strains.  Sometimes 
acute  infections  lead  to  it.  It  is  much  more  common  in  males  than  in 
females,  and  usually  appears  between  twenty-live  and  forty  years  of  age. 

Morbid  Anatomy. — The  sclerosis  implicates  both  the  lateral  and 
posterior  columns,  but  sometimes  one,  sometimes  the  other  with  greater 
intensity.  The  columns  of  Goll,  usually  commencing  above  the  lumbar 
enlargement,  are  degenerated  to  the  medulla.  The  columns  of  Burdach 
are  also  aifected  mainly  above  the  lumbar  enlargement,  but  less  in- 
tensely, and  the  root-zone  usually  escapes.  The  crossed  pyramidal  tract 
is,  as  a  rule,  partially  afPected,  its  inner  portion  being  customarily 
spared.  Its  lesion  is  slight  in  the  cervical  region,  and  increases  in  the 
lower  dorsal  and  lumbar  portions  of  the  cord.  The  direct  pyramidal 
tract  is  only  affected  when  the  lesions  are  intense  in  the  upper  cervical 
region,  and  even  then  but  slightly.  The  direct  cerebellar  tract  is  always 
intensely  affected.  The  ascending  tract  of  Goioers  sometimes  escapes, 
sometimes  is  partially  affected.  The  gray  substance  is  usually  intact. 
Rarely  the  anterior  cornual  cells  or  those  of  the  posterior  horn  or  of 
Clarke's  column  may  be  slightly  modified. 

The  sclerotic  areas  differ  from  the  degenerated  portions  of  a  tabetic 
cord  in  presenting  hypertrophied  axes-cylinders,  many  spider-cells,  and 
notable  changes  in  the  blood-vessels.  The  alteration  in  the  nervous 
tissue  is  also  proportionate  to  the  vascular  lesions  and  most  intense  in 
their  neighborhood.  Occasionally  a  chronic  meningitis  is  present. 
Cranial  nuclear  involvement  has  been  found  in  some  cases. 

To  sum  up,  the  lesion  is  of  a  myelitic  character  rather  than  that  of 
a  pure  parenchymatous  Wallerian  degeneration.  It  affects  the  posterior 
columns  from  the  lower  dorsal  area  upward  and  the  lateral  tracts  from 
the  cervical  region  downward  in  increasing  intensity,  precisely  as  do 
secondary  degenerations.  The  lesion  is  indiscriminate  in  localization 
and  bears  a  close  relation  to  the  arterial  supply  of  the  part. 

Symptoms. — The  symptoms  of  the  combined  scleroses  are  those 
of  spastic  paraplegia  and  locomotor  ataxia  variously  combined  and 
associated.  One  case  shows  a  preponderance  of  ataxia,  another  of  spas- 
ticity, depending  upon  the  distribution  and  intensity  of  the  lesion  in 
the  posterior  or  lateral  columns  and  upon  its  vertical  extent.  Lesions 
of  these  tracts  give  us,  on  the  part  of  the  posterior  columns,  incoordi- 
nation, an  ataxic  gait,  Romberg's  sign,  diminished  or  lost  reflexes,  lan- 
cinating pains,  anesthesias  and  paresthesias,  ocular  symptoms,  vesical  and 
genital  derangements,  etc.  Related  to  the  lesion  of  the  lateral  tracts 
we  have  exaggeration  of  tendon  reflexes,  foot-clonus,  motor  enfeeble- 
ment,  cramps,  spasms,  and  the  spastic  gait.  By  their  association  in 
posterolateral  sclerosis  we  usually  find  ataxia  and  spastic  weakness, 
with  increased  tendon  reflexes,  well  marked  in  the  lower  limbs,  less  pro- 
nounced in  the  upper  extremities,  and  cranial-nerve  symptoms  are  sel- 
dom entirely  absent. 

The  onset  of  the  disease,  when  not  due  to  a  diffuse  myelitis  of  more 
or  less  acute  character,  is  insidious.  One  of  the  earliest  complaints  is 
that  of  becoming  readily  tired  in  walking,  the  legs  feeling  heavy  and  weak. 
Some  ataxia  soon  presents  itself,  as  is  shown  by  the  unstable  station  with 


446  DISEASES  OF  THE  CORD  PROPER. 

closed  eyes,  or  difficulty  in  turning  or  walking  under  the  same  condi- 
tion. The  knee-jei'hs  will  be  found  increased  in  activity  and  amplitude. 
The  cutaneous  reflexes  may  be  increased  or  diminished.  The  cremaster 
is  usually  inactive.  Muscular  weakness  can  be  easily  detected.  The 
muscles  do  not  lose  their  contours  and  are  often  firm  to  the  touch,  but 
are  incapable  of  strong  contraction.  The  ataxia  increases ;  the  gait  be- 
comes very  uncertain,  with  a  tendency  to  sprawling,  and  at  the  same 
time  it  is  spastic,  so  that  the  feet  are  not  readily  brought  forward,  and 
they  may  be  shaken  by  clonus,  which  is  often  easily  developed  in  the 
calf  and  rectus  femoris  muscles.  Some  vesical  weakness  is  very  com- 
monly encountered,  and  loss  of  sexual  appetite  is  frequent,  though  erec- 
tions and  even  painful  priapism  may  annoy  the  patient. 

Sensory  symptoins  are  much  less  common,  and  when  present  are  ex- 
tremely slight  as  compared  with  tabes.  Instead  of  lightning  pains  we 
find  dull  aches,  usually  in  the  thighs  and  small  of  the  back  and  over  the 
sacrum.  Paresthetic  sensations  are  not  uncommon,  but  actual  anesthesia 
or  any  considerable  blunting  of  tactile  sensation  is  very  rare.  The 
girdle  pain  is  occasionally  present.  Visceral  crises  are  not  common,  and 
are  not  severe  when  they  do  occur.  Rectal  and  vesical  tenesmus  and 
painful  cramps  in  the  legs  at  night  are  sometimes  the  source  of  much 
complaint,  and  the  corresponding  sphincters  may  be  impaired  in  excep- 
tional cases.  There  is  often  inability  to  satisfactorily  empty  the  bladder 
and  bowels.     Urinary  retention  may  then  lead  to  cystitis. 

The  upper  extremities  almost  invariably  show  an  exaggeration  of  the 
tendon  reflexes,  and  some  rigidity  and  weakness  is  not  infrequent.  An 
exaggerated  jaw-jerk  may  be  easily  demonstrated  in  most  instances. 
Tremulous  twitchings  in  the  tongue  and  face  are  not  rare,  and  speech 
may  be  thickened  slightly,  even  in  the  cases  not  associated  with  paretic 
dementia.  Pupillary  symptoms  are  not  uncommon,  but  the  light-reflex 
is  rarely  lost  when  accommodative  contraction  persists.  Inequalities 
of  the  pupils,  irregularities  of  outline,  and  sluggishness  of  motility  to 
various  stimuli  are  frequently  noted.  The  mental  state  is  ordinarily 
normal,  but  there  may  be  some  loss  of  memory,  dependent,  mainly,  on 
lack  of  concentration  and  attention.  Prolonged  mental  application  is 
usually  impossible.     In  short,  it  is  a  neurasthenic  state. 

As  the  disease  progresses  the  paresis  in  the  legs  and  the  spasticity 
increase.  The  static  ataxia  is  also  exaggerated  actually  and  also  by  the 
increased  weakness.  Finally,  the  patient  is  unable  to  walk  and  the 
spastic  ataxia  becomes  marked  in  the  arms.  The  paraplegic  state  is 
thus  induced,  but  sensory  disturbance,  as  a  rule,  is  insignificant  to-  the 
last. 

Course. — While  the  disease  is  progressive  it  is  much  less  rapid  in  its 
course  than  tabes,  and  the  great  majority  of  cases  never  become  entirely 
unable  to  walk.  Of  itself  it  rarely  causes  death.  Bedsores,  cystitis, 
and  kidney  disease  are  the  chief  dangers.  Intercurrent  aifections  neces- 
sarily find  victims  in  these  devitalized  subjects.  The  cases  that  com- 
mence as  tabes  or  as  myelitis  present  features  referable  to  their  origin. 
Early  loss  of  knee-jerks,  the  presence  of  girdle  pains,  anesthesias, 
analgesias,  or   joint-lesions  with  spastic   features  in   the   upper  spinal 


DISEASES  OF  THE  WHITE  3IATTER  OF  THE  CORD.  447 

levels  are  probably  clue  to  myelitic  extension  from  a  posterior  sclerosis. 
Those  presenting  rapid  onset  and  girdle  features  and  localized  atrophies 
are  usually  attril)utahle  to  diffuse  myelitis. 

Diagnosis. — The  diagnosis  of  progressive  spastic  ataxia,  which  is 
the  best  descriptive  name  for  this  symptom  group,  depends  upon  the 
muscular  weakness,  the  ataxia,  the  spasticity,  and  the  progressiveness  of 
the  disease.  In  early  stages  when  the  ataxia  is  prominent  it  is  usually 
mistaken  for  tabes,  but  the  muscular  weakness,  the  increased  reflexes, 
the  insignificant  sensory  disturbance,  the  absence  of  girdle  pains,  and 
visceral  crises  should  at  once  differentiate  it.  In  later  stages  wdien  the 
paraplegic  features  are  preeminent  the  ataxia  is  lost  in  the  motor  extinc- 
tion, but  a  history  of  it  can  usually  be  obtained.  Cross  or  focal  lesions 
are  now  sometimes  thought  of.  The  sensory  integrity  and  the  presence 
of  symptoms  in  the  arms  and  in  the  cranial  nerves  should  serve  to 
exclude  such  limited  lesions.  The  family  ataxias  present  a  somewhat 
similar  symptomatology,  and  the  cord-lesion  has  about  the  same  distribu- 
tion. The  familial  features,  the  nystagmus  and  articular  disturbance, 
its  occurrence  in  early  life,  and  in  the  type  of  Friedreich  the  absent 
patellar  reflex,  should  make  the  diagnosis  plain.  Cerebellar  tumor  can 
induce  ataxia,  increased  knee-jerks,  and  weakness  in  the  legs,  but  also 
usually  has  vomiting,  occipital  pain,  choked  disc,  and  retracted  head,  and 
may  have  forced  attitudes  or  movements  to  distinguish  it. 

Prognosis. — The  slowly  progressive  tendency  of  the  disease  has 
been  sufficiently  insisted  upon.  Stationary  periods,  or  those  compara- 
tively so,  are  very  common,  and  even  improvement  in  the  individual 
features  of  some  cases  are  not  infrequent.  Complete  relief,  in  the  nature 
of  things,  is  an  impossibility,  and  the  onward  course  of  the  paretic  and 
spastic  features  is  taken  up  sooner  or  later.  Mental  disturbance,  while 
uncommon,  may  appear  and  paretic  dementia  ensue.  Every  case  is  to 
be  judged  by  itself.  The  rapidity  or  slowness  of  development  in  the 
early  years  of  the  malady  is  likely  to  mark  it  throughout.  As  already 
indicated,  only  a  small  portion  of  the  cases  reach  absolute  helplessness. 

Treatment. — The  treatment  of  a  case  of  progressive  spastic  ataxia 
will  be  modified  by  its  variety  and  origin.  When  secondary  to  tabes, 
the  treatment  is  the  same  as  in  that  disease.  The  history  of  syphilis  is 
even  a  stronger  indication  for  antiluetic  treatment  than  in  tabes,  as 
syphilitic  activity  may  directly  influence  the  condition  of  the  cord  and 
be  amenable  to  proper  medication.  Counterirritation  over  the  spine, 
spinal  stretching,  and  exercises  to  reestablish  coordinate  motor  control 
are  valuable.  Thermic  baths,  and  hydrotherapy  generally,  here  find 
a  very  useful  application.  As  a  rule,  the  use  of  hot  douches,  sprays, 
and  baths  lessen  the  spasticity,  but  in  rare  cases  cold  to  the  back  has 
the  better  effect.  Massage  of  the  muscles  and  graduated  exercises  are 
important,  but  the  fatigue  point  should  be  carefully  estimated  and  never 
exceeded.  To  this  end  the  paretic  features  are  the  guide,  and  the  sen- 
sation of  fatigue  the  criterion.  Owing  to  the  hyperexcitability  of  the 
reflexes,  massage  sometimes  is  not  well  borne.  General  measures  look- 
ing to  the  physical  health  and  the  mental  quietude  of  these  patients  add 


448  DISEASES  OF  THE  COED  PROPER. 

to  their  comfort  and  to  the  length  of  life.  The  bladder  condition  should 
receive  constant  watchfulness,  as  a  high  degree  of  retention  may  develop 
without  attracting  the  patient's  notice. 


COMBINED  CORD-LESIONS  IN  ANEMIAS  AND  CACHEXIAS. 

Nonne  was  the  first  to  demonstrate  decided  changes  of  the  spinal  cord 
in  cases  of  pernicious  anemia.  Somewhat  similar  changes  in  the  retina 
were  well  known,  and  apparently  identical  degenerations  take  place  in 
the  brain.  This  observer  found  degenerative  changes  in  the  cords  of 
ten  out  of  seventeen  cases  of  pernicious  anemia  though  symptoms  refer- 
able to  the  cord  had  been  observed  in  but  two.  The  changes  are  prin- 
cipally located  in  the  white  matter  of  the  cord,  and  show  a  decided 
tendency  to  mainly  affect  the  posterior  half,  giving  rise  to  a  group  of 
symptoms  referable  to  the  posterior  and  lateral  tracts.  In  some  in- 
stances, however,  the  anterior  portion  of  the  cord  and  even  the  gray 
matter  is  involved.  By  experimentally  induced  anemia  in  the  brain 
and  cord  Massaro,  Sciciliano,  and  Soukhanoff  have  demonstrated  similar 
cellular  changes  in  animals.  Teichmueller,  Minnich,  Lichtheim,  in  Ger- 
many, Russell,  Batten,  Collier,  in  England,  Dana,  Putnam,  Riggs,  and 
Billings,  in  this  country,  among  many  others,  have  not  only  confirmed 
Nonne's  findings  but  broadened  the  general  field  of  degenerative  condi- 
tions secondary  to  depraved  physical  states.  The  consensus  of  opinion 
now  seems  to  be  that  the  cord  changes  are  due  to  a  toxic  process, 
secondary  to  many  seriously  debilitating  systemic  conditions,  acting  upon 
a  nervous  system  of  deficient  attributes,  shown  either  by  a  marked 
neurotic  heredity  or  by  general  physical  defects.  ^  The  operation  of  the 
toxic  process  is  apparently  by  way  of  the  vascular  apparatus,  giving  rise 
to  hemorrhagic  or  interstitial  changes  resulting  in  more  or  less  sclerotic 
transformation. 

Women  are  affected  nearly  three  times  as  frequently  as  men. 

Symptoms  usually  appear  after  the  age  of  thirty,  most  commonly  in 
the  fourth  decade  of  life.  In  addition  to  the  features  of  the  anemias 
and  cachexias  and  the  conditions  arising  from  these  states,  there  is  often 
a  decided  mental  irritability.  Atrophy  of  the  optic  nerve  has  been  ob- 
served in  some  instances.      Epileptiform  attacks  have  occurred. 

The  symptoms  referable  to  the  spinal  cord  are  those  of  ataxia,  spas- 
ticity, and  weakness,  variously  combined,  giving  rise,  as  a  rule,  to 
an  ataxic  paraplegia  similar  to  that  described  in  the  foregoing  section. 
Early  in  the  disorder  the  tendency  is  to  increased  reflexes,  which  -later 
tend  to  subside  or  may  entirely  disappear  or  persist.  In  some  cases  the 
knee-jerk  is  lost  early.  Girdle  sensations  are  not  uncommon.  Pares- 
thesise  occur  from  the  first  and  are  persistent.  Neuralgias  are  common, 
so  that  multiple  neuritis  is  often  suspected.  Bed-sores,  cystitis,  and 
sphincteric  palsy  may  be  encountered  in  terminal  states  exceptionally. 

The  duration  of  the  disorder  is  variable.  Many  cases  reach  a  pro- 
found degree  of  exhaustion  before  the  cord  symptoms  develop,  in  which 
case  they  are  likely  to  rapidly  attain  a  severe  grade.  In  other  instances 
1  Putnam  and  Taylor,  "Jour,  of  Ment.  and  Nerv.  Dis.,"  Jan.,  1901. 


DISEASES  OF  THE  WHITE  MATTER  OF  THE  CORD. 


449 


paresthesia,  increased  reflexes,  and  motor  weakness  come  on  insidiously 
and  endure  for  a  number  of  years,  the  creneral  physical  state  being 
relatively  but  little   impaired.      In  a  general  way  these  cases  last  from 


Fig.  197. 


Fig.  198. 


Fig.  199. 

Figs.  197,  198,  and  199.— Sections  from  three  spinal  cords  showing  degenerations  due  to  pernicious 

anemia  (Billings). 

one  to  five  years,  the  tendency  being  steadily  for  the  worse,  though 
slight  remissions  may  be  encountered.  In  some  instances  the  paralytic 
and  sensory  disturbance  becomes  rather  rapidly  greater  in  the  lower 
extremities  and  steadily  mounts  upward  like  an  ascending  myelitis  or 
29 


450  DISEASES  OF  THE  COED  PROPER. 

may  advance  and  recede  many  times.  The  nltimate  outcome  is  almost  in- 
variably fatal,  and  the  prognosis  depends  mainly  upon  the  systemic  state. 
The  treatment  is  that  of  the  anemia  or  underlying  cachexia,  the 
secondary  toxic  conditions,  and  the  resulting  changes  in  the  cord.  The 
disabilities  arising  from  involvement  of  the  cord  have  to  be  met  by 
gymnastics,  exercises,  and  massage. 

FAMILY  ATAXIA. 

In  1861  Friedreich  reported  several  cases  of  ataxia  occurring  in  the 
children  of  one  family.  They  presented,  among  many  symptoms,  the 
loss  of  the  patellar  reflex,  incoordination  of  all  four  extremities,  nys- 
tagmus, disturbance  of  articulation,  and  a  progressive  tendency  to  help- 
lessness. Similar  cases  have  since  been  reported  in  every  country,  until 
hundreds  may  be  collected  from  the  literature.  In  some  instances  the 
disease  is  found  to  appear  in  several  generations,  but,  ordinarily,  it  is 
confined  to  a  single  family,  and  usually  appears  before  adolescence. 
To  th«  symptom  group  presented  by  these  cases  the  name  of  Friedreich's 
disease,  or  FriedreicKs  ataxia,  has  been  given. 

In  1880  Eraser  i  reported  a  series  of  cases  extending  through  sev- 
eral generations,  marked  by  the  same  symptoms  as  occur  in  Friedreich's 
group,  excepting  that  the  reflexes  were  increased  and  ankle-clonus  some- 
times present.  Nonne,  in  1891,  reported  a  similar  family,  and  clearly 
pointed  out  the  features  in  which  the  cases  falling  under  his  observation 
differed  from  the  Friedreich  variety,  and  especially  the  fact  that  they 
developed  later  in  life, — namely,  during  or  after  adolescence, — and  that 
they  frequently  showed  visual  defects  and  optic  atrophy.  Early  exam- 
inations of  Friedreich's  form  discovered  spinal  sclerosis,  embracing  the 
posterolateral  area  throughout  the  cord,  and  a  cord  of  diminutive  size 
in  some  instances.  To  this,  in  some  cases,  is  added  an  undersized  cere- 
bellum and  cranial-nerve  lesions.  In  one  of  Nonne's  cases  only  an  ex- 
treme smallness  of  the  cerebellum  and  cord  was  found.  Switalski  ^ 
reports  a  case  showing  diminutive  proportions  in  cord  and  cerebellum, 
degenerations  of  Goll's  columns,  the  direct  cerebellar  tract,  Gowers'  tract 
and  some  atrophy  of  the  anterior  horn  cells.  The  cerebellum  showed 
a  diminished  number  of  convolutions,  separated  by  deep  fissures,  and  a 
paucity  of  white  substance.  A  family  very  similar  to  those  of  Eraser 
and  Nonne  was  reported  by  Sanger  Brown,  ^  and  autopsy  on  one  of  his 
cases  showed  no  gross  cerebellar  defect*  Transition  cases  ^  are  being 
observed  that  furnish  every  intermediate  variety  between  the  spinal 
cases  on  the  one  hand  and  the  cerebellar  cases  on  the  other.  Eof  the 
latter  group  Marie  has  used  the  designation  pseudoataxie  cerebelleuse, 
and  hereditaria  cerebellar  ataxia.  Senator  ^  sees  in  Friedreich's  ataxia 
only  the  manifestations  of  teratological  cerebellar  and  spinal  defect. 
In  the  cases  of  Nonne  and  others  marked  by  cerebellar  atrophy,  or, 
more  probably,  cerebellar  agenesis,  the  same  origin  is  apparent,  and  the 
variety  of  clinical  cases  and  anatomical  findings  seems  to  depend   upon 

1  "Glasgow  Med.  Jour.,"  1880.  ^  "  Nouv.  Icon,  de  la  Salpet.,"  Sept.,  1901. 

3  "Brain,"  1892.  *  "Brain,"  1897. 

5  Haushalter,  "  Eev.  de  Med.,"  1895.    «  "  Berlin,  klin.  Wochens.,"  1893. 


DISEASES  OE  THE  WHEfE  MATTER  OF  THE  CORD. 


451 


the  location  of  the  principal  defect.  The  familial  and  hereditary- 
features  of  these  cases  at  once  declare  their  embryonic  character  and 
origin.  The  portions  of  the  cord  tliat  nndergo  sclerotic  changes  are 
precisely  those  which  are  last  to  develop  and  become  myelinated,  only 
reaching  completion  at  the  end  of  the  ninth  or  in  the  tenth  month. 

Etiology. — The  most  important  etiological  feature  of  the  family 
ataxias  is  their  embryological  nature.  Why  a  mother  should  give  birth  to 
several  children  with  defective  nervous  structures  or  other  teratological 
defects  it  is  impossible  to  say,  though  phthisis  and  other  exhausting 
cachexise  have  presented  in  some  of  these  parents.  As  is  common  in 
familial  nervous  diseases,  there  is  a  tendency  to  a  preponderance  of 
males,  and  the  transmission  is  usually  by  the  female  line.  Both  of 
these  points  are  illustrated  in  the  genealogical  diagram  of  Brown's  cases 
(Fig.  200).      In  a  given  family  there  is  frequently  noted  a  tendency  for 


Fig.  200.— Family  tree  of  hereditary  ataxia,  reported  by  Dr.  Sanger  Brown.  Explanation  of 
diagram:  Shaded  inclosures  indicate  hereditary  ataxia.  Squares  indicate  males;  circles  females.  The 
nuinbers  to  the  left  refer  to  the  cases  in  Brown's  paper  ;  the  first  number  to  the  right,  the  age  at  death 
or  the  present  age.    f  indicates  deceased.    The  last  number  indicates  the  age  at  onset. 


the  disease  to  be  manifest  at  a  progressively  earlier  age  in  successive 
children.  The  symptoms  are  likely  to  appear  at  the  developmental 
periods  of  life.  In  some  cases  they  are  congenitally  evident ;  in  others 
the  first  or  second  dentition,  the  ages  of  puberty,  adolescence,  and  com- 
plete adult  sexual  differentiation  and  reproductive  ability  seem  to  make 
demands  that  the  defective  neural  apparatus  can  not  meet,  and  there- 
after retrogrades.  In  exceptional  cases  the  disease  appears  late  in  life. 
Friedreich's  type  usually  occurs  before  the  age  of  fourteen ;  hereditary 
cerebellar  ataxia,  or  Marie's  form,  after  pubescence.  In  many  cases, 
especially  in  children,  and,  therefore,  usually  in  Friedreich's  variety,  the 
occurrence  of  an  infectious  fever  appears  to  precipitate  the  symptoms 


452 


DISEASES  OF  THE   CORD   PEOPER. 


of  the  disease.  In  these  cases,  too,  the  cord-lesions  correspond  to  those 
of  the  combined  scleroses  and  occupy  the  posterior  arterial  field  of  the 
cord's  cross-section.  The  embryonic  vulnerability  of  this  portion  of  the 
cord  may  serve  to  locate  the  lesions  in  these  instances  in  the  lower  levels 
through  the  intermediary  of  the  vascular  supply  and  the  action  of  toxic 
factors. 

Morbid  Anatomy. — The  morbid  anatomy  of  these  family  ataxias 
varies  as  the  case  corresponds  to  the  spinal  or  the  cerebellar  type.  The 
cases  that  conform  strictly  to  Friedreich's  syndrome  show  a  posterolateral 
sclerosis  analogous  in  distribution  to  that  of  progressive  spastic  ataxia. 
There  is  a  decided  sclerosis  of  the  columns  of  Goll  and  Burdach,  with 
shrinking  of  the  cord  in  this  region  throughout  its  entire  length.  There 
is  sclerosis  of  the  crossed  pyramidal  tract,  of  Goivers'  tract,  of  the  direct 
cerebellar  tract,  of  Lissauer's  tract,  and  frequently  atrophy  of  the  cells  of 
Clarice's  column.  The  posterior  horn  and  its  cells  are  shrunken  and  in 
rare  cases  the  anterior  cornual  cells  are  degenerated.  Marie  insists  that 
the  changes  in  the  pyramidal  tract  are  confined  to  the  fibers  related  to  the 


Fig.  201. — Dorsal  cord-section  in  Friedreich'.?  disease,  showing  distribution  and  relative  intensity  of 

sclerotic  changes  (Marie). 


direct  cerebellar  tracts  and  Gowers'  tracts,  and  do  not  directly  affect  the 
upper  motor  neurons.  The  portions  of  the  cord  that  la.st  develop  are 
thus  affected  by  the  retrogressive  changes  of  the  malady.  As  a  rule, 
the  cord  is  undersized  and  may  present  only  two-thirds  of  its  usual 
thickness.  In  a  few  cases,  notably  that  of  Menzel,  the  medulla  and 
cerebellum  were  also  reduced  in  size  and  degeneration  has  been  traced 
into  the  cerebrum.  The  postei^ior  roots  and  ganglia  are  usually  normal. 
Rennie,^  however,  found  degeneration  of  posterior  root-fiber.'*  and 
posterior  root-zones.  The  cranial  nerves  are  generally  spared  in  the 
spinal  variety,  but  the  hypoglossus  and  optic  nerves  have  been  found 
di.seased. 

The  cerebellar  form,  in  the  few  cases  on  record,  has  presented  atrophy 
of  the  cerebellum,  as  in  Fraser's  case,  in  one  of  Nonne's,  in  Switalski's, 
etc.  This  is  absent  in  Brown's  first  autopsy,  but  the  cerebellar  tracts  in 
the  cord  were  involved.  This  atrophy  is  said  not  to  be  sclerotic.  The 
gray  substance  is  abnormally  thin,  Purkinje's  cells  are  few  in  number 
1  "Br.  Med.  Jour.,"  July  15,  1899. 


DISEASES  OF  THE  WHITE  MATTER  OF  THE  CORD.  453 

and  undersized,  the  white  matter  is  less  vohiminous  than  usual,  and  the 
weight  of  the  organ  is  reduced  a  third  or  a  half.  The  cord  in  these 
cases  of  Marie's  type  is  undersized,  but  shows  no  sclerotic  degenerations. 
Tliere  appears  to  be  a  pure  genetic  pov^erty  of  fibers,  or  else  they  have 
disappeared,  leaving  no  trace.     Optic  atrophy  is  not  infrequent. 

Symptoms. — The  motor  symptoms  are  the  most  prominent.  They 
commence  with  clumsiness,  especially  in  walking.  The  child  stumbles 
over  every  trifle  and  becomes  more  and  more  unsteady  on  its  feet. 
Later  the  gait  is  staggering  and  drunken  in  its  uncertainty.  Ataxia 
marks  every  movement  and  position,  but  there  is  no  rigidity  even  in 
the  cases  presenting  increased  reflexes.  All  movements  are  clearly 
intentional,  though  clumsily  executed,  and  have  for  their  purpose  to 
maintain  the  insecure  equilibrium.  In  standing  the  body  is  constantly 
swaying,  and  shuffling  steps  in  various  directions  are  frequently  taken 
to  maintain  the  balance.  With  closed  eyes  the  difficulties  of  the  station 
and  gait  are  not  notably  increased,  and  there  is  practically  no  loss  of 
the  muscular  sense,  only  an  ataxic  incoordination  in  executing  move- 
ments. Frequently  coarse,  rhythmic,  trembling  or  jerky  movements  are 
made  on  attempts  to  use  the  extremities,  and  at  rest  often  a  finger 
or  the  wrist,  shoulder,  elbow,  head,  or  lower  extremity  is  moved  or 
twitched  in  a  spasmodic  manner.  Such  movements  are  frequently  seen 
in  the  face,  especially  when  the  patient  begins  to  talk  or  when  some  emo- 
tional expression  is  called  out.  Ordinarily,  complete  support  of  the  part 
or  its  complete  rest  causes  them  to  cease.  The  head,  in  a  similar  way, 
nods  in  one  direction  or  another,  and  may,  in  late  cases,  roll  around  on 
the  shoulders  as  if  articulated  with  ball  and  socket.  As  the  patient 
sits,  the  body  may  also  sway  about  above  the  hips.  An  examination 
of  the  muscular  strength  finds  it  but  slightly  reduced,  and  clearly  indicates 
^hat  there  is  no  serious  paralytic  state  present.  The  muscles  do  not 
waste  except  in  cases  of  long  standing,  and  then  only  rarely  and  mainly 
about  the  shoulders  and  hands. 

The  sensory  symptoms  are  objectively  and  subjectively  very  slight  or 
entirely  wanting.  A  few  cases  have  pains  or  even  darting  pains  in  the 
early  stages.  The  presence  of  anesthesia  or  analgesia  should  raise  a  sus- 
picion of  hysteria.     The  muscular  sense  is  practically  perfect. 

The  superficial  reflexes  are  not  disturbed.  In  cases  of  the  Friedreich 
type  the  deep  reflexes  are  diminished  or  abolished  and  the  knee-jerk 
usually  disappears  very  early.  In  Marie's  form  the  deep  reflexes  are 
exaggerated  and  foot-  and  rectus-clonus  are  commonly  encountered. 
The  sphincters  are  unaffected. 

The  face  presents  an  appearance  of  hebetude  that  deepens  as  the 
disease  advances  and  in  some  instances  first  calls  attention  to  its  inva- 
sion. The  features  droop  in  a  mask-like  blankness  of  expression, 
often  intensified  by  a  half-open  mouth.  In  emotional  expression 
the  ataxic  unbalance  appears,  resulting  in  contortions,  or,  at  least, 
exao-gerations  of  facial  movements.  There  is  usuallv  well-marked 
nystagmus.  The  oscillations  of  the  globe,  however,  tend  to  cease  if  the 
eye  is  allowed  to  remain  at  rest,  and  vary  in  amplitude  and  are  increased 
by  effort,   like   all  the   other   manifestations    of   incoordinate   muscular 


454 


DISEASES  OF  THE   CORD   PROPER. 


balance.  It  is  ofteni  necessary  to  direct  the  eyes  widely  from  the  direct 
line  of  forward  vision  to  develop  the  nystagmic  jerking.  This  can 
usually  be  accomplished  by  having  the  patient  fix  his  eyes  upon  an 
object  in  an  outward  and  upward  direction.  Palsies  of  the  ocular 
muscles  are  extremely  rare.  Joifroy  has  published  one  case,  and  another 
is  illustrated  here.  In  Friedreich's  form  optic  atrophy  is  a  rare  excep- 
tion. Small  1  reports  three  out  of  four  cases  in  one  family  showing 
some  degree  of  it.  In  Marie's  form,  on  the  other  hand,  it  is  a  com- 
mon finding,  and  changes  in  the  visual  ae?«Y?/and  in  the  form-  and  color- 
jieJds  are  frequently  encountered.  The  pvpiUary  reflex  is  usually  normal 
in  Friedreich's  form,  but  may  be  aifected  in  ]\Iarie's  group. 

The  speech  is  ataxic,  if  the  expression  may  be  used.  Modulation 
of  the  voice  and  prompt  enunciation  are  defeated  by  the  tardy  and  inco- 
5rdinate  action  of  the  muscular  apparatus.  It  reminds  one  of  the  gait ; 
some  words  come  quickly,  others  slowly,  and  the  voice  tones  change 
suddenly   and    irregularly  in    pitch    or    other    qualities,   though    tend- 


^' 

Fig.  202. — Apathetic  facies  in  Friedreich's  ataxia.     1,  O.  F.,  eight  years  old,  affected  one  year ;  2,  F.  F., 
seventeen  years  old,  aifected  three  years  ;  3,  K.  F.,  twenty  years  old,  aifected  five  years. 


ing  to  a  monotone.  The  intelligence  of  these  patients  is  not  much 
impaired  in  the  early  years  of  their  malady,  and  is  often  belied  by 
their  apathetic  and  empty  faces,  but  in  the  later  stages  of  the  disease 
the  mind  is  frequently  sluggish  or  shows  some  retardation  of  develop- 
ment. In  Friedreich's  form  physical  development  is  also  frequently 
retarded  if  the  disease  manifests  itself  before  puberty,  and  sexual  func- 
tions are  correspondingly  backward. 

Trophic  and  voMomotor  defects  are  very  rarely  encountered,  or  are 
entirely  lacking  except  a  peculiar  conformation  of  the  feet  and  a  slight 
vertebral  scoliosis  that  are  frequent  in  Friedreich's  form.  The  club- 
foot  consists  of  an  exaggeration  of  the  plantar  arch  which  shortens 
the  foot  notably  and  causes  the  toes  to  assume  the  "hammer"  jDosi- 
tion,  extended  at  the  first  and  flexed  at  the  other  phalanges.  This 
is  particularly  marked  in  the  big  toe,  which  usually  is  first  aifected 
and  is  sometimes  the  first  symptom  of  the  disease  detected  by  rela- 
tives conversant  with  its  forms.  The  deformity  is  increased  when  the 
1  '-Med.  Record,"  N.  Y.,  July  20,  1895. 


DISEASES  OF  THE  WHITE  MATTER  OF  THE  CORD.  455 

I 
foot  is  extended  upon  the  leg,  and  if  slightly  marked,  may  disappear 
when  the  patient  is  standing.  A  similar  deformity  of  the  foot  is  also 
encountered  in  some  of  the  family  and  sporadic  cases  of  progressive 
muscular  atrophy.  The  scoliosis  appears  in  most  of  the  well-developed 
cases  of  Friedreich's  form,  and  occupies  the  dorsal  and  lumbar  spine. 
It  is  usually  slight. 


Fig.  203.— Clubbed  foot  of  Friedreich's  disease,  showing  shortened  arch  and  retracted  great  toe. 

Varieties. — The  two  major  varieties  making  up  the  group  of  family 
ataxias  have  been  indicated  throughout  the  preceding  pages,  and  there 
are  many  authoritative  writers  who  regard  them  as  distinct  entities. 
Their  principal  diiferences  are  contained  in  the  following  table.  The 
cerebellar  features  clinically  predominate  in  both  and  autopsies  are  yet 
too  few  to  justify  their  complete  separation,  especially  as  all  inter- 
mediate varieties  are  being  reported  : 

Friedreich's  Form.  Marie's  Form. 

Hereditary  spinal  ataxia   appears  usu-  Hereditary    cerebellar    ataxia    appears 

ally  before  puberty.                            _  usually  after  puberty. 

■Choreic  movements  in  upper  extremi-  Very  common  and  pronounced. 

ties  and  oscillations  in  head  and  trunk 

frequent. 

Optic  atrophy  and  amblyopia  very  ex-  Common. 

ceptional. 

Tendon  reflexes  diminished  or  absent.  Increased,  foot-clonus  frequent. 

Club- foot  and  scoliosis  common.  Exceptional. 

Course. — The  first  symptoms  to  attract  attention,  unless  the  case  is 
congenital,  are  the  difficulties  in  walking.  Sometimes  certain  families, 
who  have  learned  to  know  the  symptoms  from  the  number  of  cases 
among  them,  recognize,  by  the  facies  or  the  scoliosis  or  the  club-foot  and 
cramped  toes,  that  another  member  has  been  added  to  the  list.  In  the 
course  of  three  to  four  years  the  ataxia  in  all  four  extremities  is  well 
marked.  It  advances  and  augments  and  in  another  similar  period  takes 
the  patient  off  his  feet  and  renders  him  practically  helpless.  In  this 
state  he  may  live  ten  to  twenty  years  and  finally  die  from  intercurrent 


456  DISEASES  OF  THE  CORD  PROPER. 

disease.  While  the  course  of  the  disease  is  commonly  steadily  pro- 
gressive, long  remissions  may  occur  and  sudden  aggravations  take  place, 
but  death  does  not  result  directly  from  the  disorder. 

Diagnosis. — The  diagnosis  of  a  case  of  family  ataxia  is  almost  self- 
evident  if  numerous  members  of  the  same  or  succeeding  generations  are 
aifected,  but  in  certain  instances  no  such  collateral  cases  exist.  The 
differential  diagnosis  must  then  be  made  from  tabes,  chorea,  and  insular 
sclerosis.  In  tabes  the  gait  lacks  the  cerebellar  quality.  Posterior 
sclerosis  also  presents  visceral  crises,  lightning  pains,  vesical  weakness, 
sensory  disturbances,  and  pupillary  symptoms.  It  is  a  disease  of  full 
adult  life,  has  commonly  a  syphilitic  history,  and  nystagmus  is  extremely 
uncommon  in  it.  The  cases  of  family  ataxia  occurring  late  in  life 
usually  present  increased  reflexes. 

From  chorea,  for  which  it  is  frequently  mistaken,  especially  in  chil- 
dren, family  ataxia  may  be  distinguished  by  the  major  affection  of  the 
upper  extremities  in  Sydenham's  disease,  its  rather  abrupt  onset,  and 
the  absence  of  nystagmus,  scoliosis,  club-foot,  and  persistent  abnormal- 
ities of  the  tendon  reflexes.  Huntingdon's  family  chorea  of  adult  life 
has  its  mental  features  and  forced  attitudes  and  movements,  which  are 
greatly  in  excess  of  anything  seen  in  the  family  ataxias. 

Insular  sclerosis  presents  the  closest  resemblance  to  family  ataxia, 
especially  Marie's  form ;  and  as  it  also  may  aflect  several  members  of 
the  same  family,  the  differentiation  may  be  most  difficult,  if  not  impos- 
sible. We  must  recall  its  distinctive  intention  tremor,  its  lack  of  static 
instability,  its  scanning  staccato  speech,  its  spastic  features  and  gait. 

Prognosis. — The  outlook  in  these  family  ataxias  is  always  gloomy. 
Aside  from  the  helplessness  there  is  no  suffering,  and,  as  a  rule,  they 
bear  their  lot  with  an  apathetic  good  nature. 

Treatment. — The  management  of  these  cases  does  not  promise 
much  improvement.  Some  have  thought  that  spinal  stretching  and 
electricity  improved  the  inco5rdination.  Carefully  planned  exercises 
may,  perhaps,  assist  in  the  same  direction. 

HEREDITARY   SPASTIC   PARAPLEGIA. 

Commencing  with  Striimpell,  groups  of  cases  have  been  recorded  by 
Bernhardt,  Philips,  South,  Newmark,!  Achard  and  Fresson,^  Bayley,^ 
and  others,  which  present  pure  spasticity  and  familial  traits.  Bayley 
traced  the  disease  through  five  generations,  the  individuals  affected 
showing  marked  similarity  in  all  respects.  In  his  series  it  seemed 
that  the  disease  once  escaped  did  not  reappear  in  the  descendants. 
Spiller  *  reports  a  family  showing  the  disease  in  eight  generations. 

The  spastic  condition  may  appear  at  any  age  from  the  first  (Achard 
and  Fresson)  to  the  fifty-sixth  year  (Striimpell)  and  very  commonly 
is  preceded  by  some  infectious  disease,  as  typhoid,  measles,  etc.  There 
is  paresis  only  in  the  terminal  stages  and  no  ataxia.  The  muscular 
hypertonus  and  increased  reflexes  are  alone  noted.     Sensory  and. sphinc- 

1  "  Med.  News,"  Feb.  16,  1897.         ^  "  Gaz.  hebdom.  de  Med  et  de  Chir.,"  Dec,  1896. 
s  "Jour.  Nerv.  and  Ment.  Dis.,"  Nov.,  1897.       ^  "Phila.  Med.  Jour.,"  June  21,  1902. 


DISEASES  OF  THE  WHITE  MATTER  OF  THE  CORD.  457 

terio  difficulties  are  absent  and  cerebral  features  are  insignificant,  or  only 
such  as  are  attributable  to  defects  in  the  intracerebral  portion  of  the 
motor  pathway.  The  leg'  rigidity  may,  however,  render  the  gait  mark- 
edly spastic  and  walking  finally  impossible. 

The  symptoms  are  referable  to  the  pyramidal  tracts  which,  with 
the  columns  of  GoU  and  the  direct  cerebellar  tracts,  were  found  degen- 
erated by  Striimpell.  Erb,^  who  called  it  a  primary  spastic  paraplegia, 
has  collected  ten  postmortem  reports  showing  the  sclerosis  to  be  mainly 
confined  to  the  lateral  portions  of  the  cord  and  principally  to  the  crossed 
pyramidal  tract.  Jendrassek  ^  believes  that  the  process  may  begin 
in  the  brain,  bulb,  or  cord,  and  is  introgressive  in  nature.  From  the 
familial  feature  of  these  cases  it  is  evident  that  the  basis  of  the  para- 
plegia is  a  teratological  defect  and  its  sometimes  late  appearance  is  no 
bar  to  such  belief. 

Treatment  promises  little,  though  massage  and  carefully  selected 
exercises  may  accomplish  something. 

The  prognosis  is  not  hopeful,  but  the  course  of  the  disease  is 
usually  very  slow  and  for  a  given  family  nearly  the  same  in  all  the 
affected  members. 


SCLEROSIS   OF   THE  CORD    DUE   TO   VEGETABLE   INTOXICANTS- 
ERGOTISM,  LATHYRISM,  PELLAGRA. 

Ergotism. — Epidemics  of  ergotism  have  arisen  in  various  localities 
of  the  Old  AVorld,  usually  in  times  of  bad  harvest,  when  the  people 
were  reduced  to  eating  ergoted  grain.  Brain  symptoms  in  the  form  of 
mania  are  often  associated,  and  epileptoid  attacks  are  common.  The 
disease  respects  neither  age  nor  sex,  and  sometimes  animals  present  sim- 
ilar cord  symptoms.  These,  in  man,  consist  of  paresthesias,  lightning 
pains,  girdle  sensations,  analgesia,  static  instability,  and  an  ataxic  gait 
with  obliteration  of  the  patellar  reflexes.  Neither  optic  atrophy  nor 
pupillary  stasis  occurs.  In  all  recent  autopsies  a  sclerosis  confined  to 
the  posterior  columns,  and  conforming  closely  to  the  changes  in  tabes, 
has  been  found.  In  many  instances  the  symptoms  develop  after  the 
poisonous  food  has  been  discontinued  for  some  months.  The  tendencv 
of  the  disease  is  toward  recovery  by  progressive  amelioration  during 
several  years.  In  some  instances  even  the  knee-jerk  is  restored.  The 
mortality,  however,  in  acute  cases,  is  rather  great.  (For  fuller  particu- 
lars the  reader  is  referred  to  the  article  of  Tuczek,  "Archiv  f.  Psy- 
chiatric," Bd.  xiii,  S.  99.) 

Lathyrism.  ^ — Epidemics  of  this  disease  in  Europe,  Africa,  and  Asia 
have  been  noted  for  centuries.  The  cases  are  marked  by  rigidity  of  the 
lower  extremities  coming  on  within  a  few  days,  and  paraplegic  symp- 
toms, with  weakness  of  the  bladder,  generally  ending  in  slow  re- 
covery. They  coincide  with  famine  conditions,  when  the  people  eke  out 
their  subsistence  with  the  various  vetches,  such  as  Lathyrus  sativus,  or 
dcera,  or  dymennm.     The  morbific  constituent  appears  to  be  an  alkaloid 

1  "Br.  Med.  Jour.,"  Oct.  11,  1902.  ^  <'Deut.  Arch.  f.  klin.  Med.,"  Bd.  Iviii. 

^  Brunelli,  "Trans.  Seventh  Internat.  Cong.,"  vol.  ii,  p.  45. 


458  DISEASES  OF  THE  COED  PROPER. 

not  destroyed  by  ordinary  cooking.  The  symptoms  come  on  gradually 
or  sometimes  rather  abruptly,  and  a  spasmodic  paraplegia  is  developed, 
producing  the  paraplegic  state,  so  far  as  motion  and  locomotion  is  con- 
cerned. Sensation  is  not  materially  disturbed,  though  paresthesias  and 
some  blunting  of  cutaneous  sensation  are  usual.  Mental  symptoms  and 
cerebral  features,  including  involvement  of  cranial  nerves,  seem  to  be 
lacking.  The  exact  lesion  is  not  known,  but  the  symptoms  all  point  to 
disturbance  in  the  lateral  tracts,  or,  perhaps,  to  a  posterolateral  sclerosis 
with  preponderating  spasticity.  Often  such  cases  suggest  a  focal  lesion 
of  the  cord,  but  the  absence  of  serious  sensory  disturbance  and  the  com- 
plete recovery  that,  as  a  rule,  ensues  are  not  consistent  with  such  a  point 
of  view. 

Pellagra  ^  is  sometimes  confounded  with  ergotism.  It  has  occurred 
mainly  in  poverty-stricken  Italian  districts,  and  is  traceable  to  the  use 
of  diseased  and  fermenting  maize.  It  produces  mental  symptoms  that 
usually  call  for  asylum  treatment.  In  an  acute  form,  called  pellag- 
rous typhus,  it  may  rapidly  cause  death,  and  then  myelitis,  enteritis, 
meningitis,  and  lymphatic  adenitis  plainly  declare  the  toxemic  nature 
of  the  malady.  Many  cases  are  marked  by  a  rough,  intense,  rapidly 
extending  erythema,  usually  commencing  about  the  neck.  Belmondo 
considers  the  disease  to  be  due  to  a  specific  organism.  Lombroso 
attributes  it  to  a  fungus  in  the  maize. 

The  cord-lesions  that  are  found  consist  of  a  leptomeningitis,  often 
with  much  thickening,  and  even  with  the  formation  of  osseous  plaques. 
In  the  cord  itself  the  anterior  cornual  cells  are  frequently  atrophied 
and  pigmented.  There  is  commonly  a  j)osterolateral  sclerosis.  This 
affects  the  colums  of  Goll  and  Burdach,  mainly  in  the  upper  cord-levels, 
but  spares  the  root-zone  of  the  postero-external  column.  The  crossed 
pyramidal  tract,  especially  the  lower  portion,  is  also  sharply  sclerosed, 
the  direct  cerebellar  tract  usually  escaping. 

The  spinal  symptoms  correspond.  Ataxia  is  most  marked  in  the 
upper  extremities ;  spasticity  is  pronounced  m  the  lower  limbs.  The 
iridian  reflexes  are  spared,  and  cutaneous  sensibility  is  not  much  affected. 
Strangely,  in  spite  of  the  usual  changes  in  the  anterior  cornual  cells, 
muscular  atrophy  is  insignificant.  The  disease,  clinically  and  anatomi- 
cally, presents  much  resemblance  to  paretic  dementia. 

^  Tuczek,  "  Monographie  sur  la  Pellagre, "  1893. 


PART  VI. 

DISEASES  OF  THE  GENERAL  NERVOUS  SYSTEM 
WITH  KNOWN  ANATOMICAL  BASIS. 


Among  the  various  diseases  that  have  already  been  described,  several 
have  presented  symptoms  referable  to  the  various  portions  of  the  entire 
nervous  apparatus  and  properly  belong  to  this  section.  Thus,  in  multiple 
neiuritis  all  nervous  levels  may  be  invaded.  Cerebral,  spinal,  and  nerve- 
trunk  lesions  are  all  encountered.  The  same  is  true  of  cerebrospinal 
meningitis,  tabes,  paretic  dementia,  bulbospinal  muscular  atrophy,  ergotism, 
lathyrlsm,  pellagra,  and  polioenceplialomyelitis  ;  but  for  purposes  of  com- 
jsarison  as  well  as  contrast  it  was  thought  most  expedient  to  take  them 
up  in  the  order  chosen,  being  guided  by  the  preponderance  of  nerve- 
trunk  or  spinal-cord  features  in  each  instance.  To  those  named  we  here 
add  multiple  insular  sclerosis  and  syphilis  of  the  nervous  system.  AYith 
some  of  the  syphilitic  lesions  we  are  already  acquainted. 


CHAPTER  I. 
MULTIPLE  CEREBROSPINAL  SCLEROSIS* 

Multiple  cerebrospinal  sclerosis — multiple  sclerosis,  insular  sclerosis, 
sclerose  en  plaques,  or  disseminated  sclerosis — is  a  disease  secondary 
usually  to  some  intoxication  or  infection  often  of  a  mixed  sort.  It  is 
marked  by  numerous  islets  or  plaques  of  sclerosis  irregularly  distributed 
in  the  brain,  cord,  and  cranial  nerves.  These  are  related  to  the  blood- 
supply  of  the  part  and  probably  primarily  vascular. 

Etiology. — This  sclerotic  disease  is  not  very  common.  For 
instance,  Uhthoff  in  six  or  seven  years  could  only  gather  about  100 
cases  from  all  the  hospitals  and  clinics  of  Berlin.  It  aiFects  both  sexes 
indifferently  and  presents  a  large  preponderance  of  cases  between  the 
ages  of  twenty  and  thirty  years.  Marie  asserts  its  absolute  rarity  after 
forty,  but  cases  do  occur.  Children  are  sometimes  affected  and  it 
may  even  be  congenital.     Considerable  stress  was  formerly  laid  upon 

459 


460 


DISEASES  OF  THE  GENERAL  NERVOUS  SYSTEM. 


heredity,  but  this  element  is  chiefly  manifest  in  a  neuropathic  tendency. 
Erb,  Oppenheim,  and  Duchenne  have  cited  examples  of  direct  succes- 
sion, and  it  has,  in  a  small  number  of  instances,  atfected  several  children 
of  the  same  family.  Hervouet  has  even  seen  nine  cases  in  one  gen- 
eration. Overwork,  cold,  traum,atisin,  and  various  excesses  have  been 
accused  as  causative.  Such  relation  is  subject  to  doubt,  though  all 
these  influences  are  capable  of  aggravating  the  disease  when  once  estab- 
lished and  of  precipitating  additional  manifestations  of  its  activity. 
Hoflman,!  for  instance,  in  a  study  of  100  cases,  attributed  the  cause  to 
trauma  in  13,  but  in  one-half  of  the  cases  no  alleged  cause  could  be 
mentioned.  The  most  important  etiological  factors  are  the  infections. 
Typhoid,  pneumonia,  malaria,  measles,  scarlet  fever,  small-pox,  diph- 
theria, whooping-cough,  erysipelas,  dysentery,  cholera,  influenza,  and 
the  puerperium  have  been  followed  by  the  development  of  the  symp- 


Fig.  204.— Lesions  of  insular  sclerosis  in  the 
brain  (Charcot). 


Fig.  205. — Lesions  of  the  insular  sclerosis 
in  the  pons  and  medulla  (Charcot). 


toms  of  multiple  sclerosis  within  a  few  weeks  or  months.  ^  Oppen- 
heim ^  found  that  in  eleven  out  of  twenty-eight  cases  treated  by  him 
the  patients  had  long  been  exposed  to  the  influence  of  lead,  copper, 
zinc,  etc.,  and  emphasizes  the  significance  of  occupations  attended  by 
such  intoxications.  Charcot,  in  one  of  his  later  lectures,  reporJ:ed  a 
case  consecutive  to  cerebral  rheumatism.  Infection  may  explain  some 
of  the  family  groups  of  multiple  sclerosis  and  Oppenheim's  observation 
of  the  disease  in  a  mother  and  child.  From  the  numerous  and  often 
mixed  infections  noted,  it  seems  unlikely  that  we  have  to  deal  with  a 
specific  organism.  It  is  also  a  debated  question  whether  the  morbific 
microbes  act  through  their  elaborated  poisons  or  by  embolic  colonization. 
It  is,  however,  quite  definitely  settled  that  the  irritative  influence 
reaches  the  central  nervous  organs  through  the  blood-channels  and  there 

1  "Deut.  Zeit.  f.  Nervenlieilk.,"  Dec,  1901.  ^  Williamson,  "  Brain,"  1896. 

3  "Berlin,  klin.  Wochens.,"  March,  1896. 


3IULTIPLE  CEBEBB08PINAL    SCLEROSIS. 


461 


sets  up  the  localized  sclerotic  processes.  Early 
sclerotic  patches  ordinarily  show  a  centrally  diseased 
blood-vessel,  and  thrombi  have  been  found  in  several 
instances  which  Ribbert,  ^  with  Marie,  is  disposed  to 
attribute  to  microbic  emboli. 

Goldscheider  ^  declares  the  process  analogous  to 
that  of  an  acute  myelitis  originating  through  the  vas- 
cular supply,  while  Schuster  and  Bielschowsky  ^  con- 
sider the  change  as  primarily  interstitial. 

Morbid  Anatomy. — llacrosoojncally  the  men- 
inges retain  their  normal  appearance.  The  pia 
mater  is  translucent  and  frequently  the  sclerotic 
patches  on  the  cerebral  and  cord  surfaces  can  be 
seen  through  it.  These  present  various  sizes  and 
shapes  and  are  usually  grayish  or  pinkish  gray  in 
color.  In  some  cases  they  may  only  appear  after 
undergoing  the  action  of  bichromate  and  other  hard- 
ening solutions.  In  distribution  they  recognize  no 
law.  Sometimes  they  are  most  frequent  on  the  sur- 
face ;  sometimes  they  are  confined  to  the  interior  of 
the  cord  and  brain.  In  a  general  way  they  seem  to 
prefer  the  white  substance  to  the  gray  matter.  They 
are  found  from  the  cerebral  convolutions  to  the  filum 
terminale  and  in  variable  numbers  from  a  few  to 
several  hundred.  Their  dimensions  are  those  of  a 
millet-seed  to  a  walnut  or  larger,  and  they  are  often 
of  irregular,  but  almost  invariably  of  definite,  outline. 
They  may  invade  the  cranial  nerves,  especially  the 
optic,  and  the  spinal  roots  are  not  exempt.  On  sec- 
tion, they  present  a  retracted  appearance  if  old,  a 
salient  aspect  if  recent.  Both  sorts  may  be  found  in 
the  same  case. 

Microscopically  the  definite  outline  of  the  plaques 
is  still  maintained,  and  they  are  sharply  distinguished 
from  the  surrounding  normal  tissue.  The  myelin  has 
disappeared  from  the  nerve-fibers  which  pass  through 
them,  but  the  axis-cylinders  usually  persist  and  some- 
times are  enlarged.  In  recent  plaques  there  is  an 
abundance  of  granular  bodies  throughout  the  islet, 
but  in  older  lesions  they  are  confined  to  the  peri- 
phery of  the  plaque.  Through  and  everywhere  in 
the  plaque  is  a  proliferation  of  the  neuroglia,  at  once 
the  evidence  and  the  result  of  the  irritant  cause  of 
the  lesion.  Observers  are  agreed  that  secondary 
degenerations  do  not,  as  a  rule,  follow  the  develop- 
ment of  these  sclerotic  patches.  Deprived  of  their 
myelin  covering,  insulation  is  probably  impaired  in 


Fig.  206.— Distribu- 
tion of  lesions  of  multi- 
ple sclerosis  in  the  cord. 
Sections  taken  at  various 
levels  throughout  its  en- 
tire length  (Charcot). 


1  Virchow's  "Archiv,"  1895.  2  "  Zeit.  f.  klin.  Med.,"  Bd.  xxx. 

3  "Neurolog.  Centralbl.,"  1897. 


462  DISEASES  OF  THE   GENERAL  NERVOUS  SYSTEM. 

the  nerve-fibers,  and  to  this  fact  some  writers  attribute  in  part  the  trem- 
bhng  and  other  motor  disturbances  commonly  presented.  Occasionally 
myelinated  fibers  are  fi3und  in  old  patches,  and  it  has  been  suggested 
that  they  may  be  due  to  a  regenerative  process.  These  particularly  occur 
in  the  pyramidal  tracts  and  in  Goll's  columns.  Popoff  insisted  that  the 
alleged  neuroglial  hyperplasia  does  not  exist,  but  regards  this  appearance 
as  due  to  degeneration  products  of  the  myelin  and  axis-cylinders.  Red- 
lich,i  however,  in  a  later  study,  insists  fully  upon  the  glial  increase 
in  all  cases.  The  nerve-cells  embraced  in  the  plaques  are  diminished 
in  size,  often  pigmented,  and  their  processes  are  atrophic  or  may  have 
disappeared. 

In  the  optic  nerve  there  is  the  same  interstitial  increase  without  division 
of  axis-cylinders,  and,  according  to  UhthofF,  papillitis  and  atrophy  of  the 
disc  only  occur  when  the  plaque  is  situated  immediately  behind  the  globe. 

The  vessels  in  the  plaques  show  decided  changes.  The  coats  are 
thickened,  especially  the  external  tunic,  so  that  in  section  they  remain 
open  and  dilated.  The  perivascular  sheaths  are  also  dilated  and  at 
times  obliterated.  In  other  instances  thrombotic  occlusion  of  the  ves- 
sels has  been  observed.  One  vessel  particularly  altered  is  usually 
found  near  the  center  of  each  small  sclerotic  patch,  and  the  sclerosis 
is  most  intense  at  and  about  this  point.  The  appearance  indicates  that 
an  early  embolism  or  thrombosis  sets  up  vascular  lesions  extending  to 
the  perivascular  spaces,  and  entails  irritative  sclerosis  of  the  adjacent 
neuroglia. 

A  certain  number  of  cases  must  be  kept  in  mind  where  the  early 
changes  are  due  to  diffuse  myelitis  or  cerebritis,  or  both,  and  in  which 
secondary  degenerations  and  numerous  focalized  softenings  give  rise  to 
a  similar  clinical  picture. 

Symptoms. — Wide-spread  as  are  the  lesions  and  haphazard  as  is 
their  location  in  multiple  sclerosis,  the  clinical  symptom  group  of  the 
disease  is  tolerably  uniform  and  ordinarily  easily  recognized. 

The  motor  features  constitute  the  most  important  group  of  symp- 
toms in  multiple  sclerosis.  The  gait  is  usually  disturbed  at  an  early 
period  of  the  disease.  Sometimes  it  is  clearly  and  purely  spastic,  identi- 
cally the  same  as  that  presented  in  the  paraplegic  state  :  legs  rigid,  knees 
adducted,  toes  turned  in  and  dragging  along  the  ground ;  clonus 
showing  in  the  trembling,  shaking  legs,  which  are  pulled  up  and 
advanced  by  swaying  movements  of  the  body  and  pelvis ;  all  re- 
flexes exaggerated.  To  this  is  usually  added  more  or  less  uncer- 
tainty of  equilibrium,  and  we  have  a  combination  of  cerebellar  stagger- 
ing and  spastic  rigidity  which  has  been  called  the  cerebellospasmodic 
gait,  and  is  the  one  most  frequently  encountered.  In  exceptional  cases 
the  gait  is  purely  cerebellar  in  quality,  without  any  rigidity,  and  with 
diminished  or  normal  reflexes.  There  is  commonly  more  or  less  muscular 
weakness,  which  may  reach  a  paraplegic  degree  and  defeat  all  attempts  at 
walking.    In  exceptional  instances  the  lower  extremities  are  not  afl^ected. 

A  considerable  proportion  of  cases  present  apoplectiform  attacks,  fol- 
lowed by  transitory  paralysis  at  some  period  of  the  disease.  In  rare 
1  "Neurolog.  Centralbl.,"  1896,  p.  562. 


MULTIPLE   CEREBROSPINAL  SCLEROSIS.  463 

instances  such  an  apo})lectiform  attack  is  tiie  initial  manifestation  of  the 
disease.^  Sometimes  both  limbs  and  the  face  on  the  same  side  are 
involved ;  sometimes  we  have  a  crossed  paralysis ;  sometimes  the  face 
escapes,  and  sometimes  the  palsy  is  paraplegic  in  distribution. 

The  upper  limbs  present  not  only  the  spastic  weakness  already 
noted  in  the  lower  extremities,  but  here  is  developed  to  its  highest  de- 
gree the  so-called  intention  tremor,  which  is  characteristic  of  the  dis- 
ease. While  at  rest  the  hands,  trunk,  and  head  are  perfectly  quiet ;  but 
once  the  patient  attempts  to  reach  any  article,  especially  if  the  movement 
be  somewhat  extensive  and  requires  precision,  the  entire  member  be- 
comes animated  with  a  coarse  trembling  which  augments  in  amplitude 
as  the  movement  continues.  Finally  the  object  is  seized  with  con- 
siderable rudeness.  The  moment  the  arm  is  again  placed  at  rest,  and 
supported  so  that  no  muscular  effort  is  expended,  the  tremor  at  once 


Fig.  207. — Handwriting  in  two  cases  of  multiple  sclerosis,  showing  irregular  intention  tremor. 

ceases.  This  tremor  shows  clearly  in  the  handwriting  of  these  patients, 
and  writing  may  finally  become  impossible.  Unlike  the  trembling  of 
paralysis  agitans,  which  is  most  pronounced  in  the  fingers  and  while  at 
rest,  the  intention  tremor  of  multiple  sclerosis  usually  arises  at  the 
roots  of  the  extremities,  and  they  are  moved  in  their  entirety  from  the 
shoulder-  or  hip-joints.  This  accounts  for  the  wide  range  of  the  tremor 
excursions,  and  perhaps  for  their  slow  rate,  which  usually  is  between 
five  and  eight  to  the  second.  The  lower  extremities  may  also  present 
this  intention  tremor  to  some  degree,  and  it  frequently  shows  in  the 
trunh  and  head  of  the  patient  if  without  back-support  or  head-rest. 
The  movements  of  the  head  are  usually  anteroposterior  in  direction,  but 
may  also  be  somewhat  lateral  and  then  tend  to  produce  circumduction 
of  the  head  upon  the  shoulders.  Frequently  the  tremor  is  much  more 
marked  on  one  side  than  on  the  other,  and  rarely  it  is  unilateral. 

One  of  the  ordinary  tests  of  this  tremor  is  to  direct  the  patient  to 
take  a  drink  from  a  tumbler  of  water.  In  marked  cases  the  tremor 
appears  directly  the  hand  starts  toward  the  glass.  This  is  reached  in  a 
fairly  direct  line,  grasped  suddenly,  and  with  increasing  oscillations 
carried  toward  the  lips,  which  are  protruded  to  meet  it,  with  the  head 
and  body  advanced  and  shaking.  The  motions  become  more  and  more 
vigorous,  and  finally  the  glass  is  rattled  or  dashed  against  the  teeth,  and 
the  water  not  already  spilled  may  drench  the  patient's  face  and  clothing. 
1  Boulogne,  "  Rev.  de  Med,"  May,  1893. 


464  DISEASES   OF   THE   GENERAL  NERVOUS  SYSTEM. 

The  little  remaining  is  obtained  by  steadying  one  hand  with  the  other, 
and  firmly  holding  the  glass  with  the  mouth.  This  tremor  is  increased 
by  embarrassing  emotioiv^,  and  is  somewhat  proportionate  to  the  extent 
and  duration  of  the  movement  attempted. 

Sensory  features  in  multiple  sclerosis,  in  a  general  fashion,  may 
be  said  to  be  insignificant,  so  far  as  general  sensibility  is  concerned. 
Occasionally  a  patient  complains  of  anomalous  sensations  of  heat  or 
cold,  formication,  fullness  in  the  limbs,  and  sometimes  of  pains  which 
may  even  be  lightning-like  in  character  or  of  the  girdling  form.  Ac- 
cording to  Freund,  the  slight  objective  sensory  changes  sometimes 
encountered  are  confined  to  the  fingers  and  toes  mainly,  and  to  the 
distal  portions  of  the  limbs.  They  consist  of  disturbance  of  touch,  of 
hyperalgesia  and  analgesia,  and  insignificant  modifications  of  thermic 
sensibility.  They  are  often  transient  and  changeable.  F.  von  Gebhardt  ^ 
claims  that  in  advanced  cases  certain  areas  present  permanently  dis- 
ordered sensation.  Hemianesthesia  and  other  hysterical  distributions 
of  anesthesia  sometimes  complicate  multiple  sclerosis,  as  the  diseases 
may  be,  and  often  are,  associated. 

Hearing,  taste,  and  smell  are  singly  disordered  in  rare  cases  of  multi- 
ple sclerosis,  usually  in  the  direction  of  deficit,  and  may  be  completely  lost. 

Disturbance  of  sight,  on  the  other  hand,  is  frequent,  often  very 
marked,  and  of  great  diagnostic  value.  The  ocular  apparatus  may  be 
affected  in  any  portion  of  its  neuromuscular  make-up.  Nystagmus, 
usually  consisting  of  lateral  movements,  is  presented  by  over  half  the 
cases,  perhaps  in  seventy  per  cent.  True  nystagmus,  in  which  the  eyes 
constantly  oscillate,  occurs  about  once  out  of  five  such  cases,  the  other 
four  presenting  nystagmiform  movements  only  on  occasion,  particularly 
when  the  eyes  are  forcibly  deviated  to  the  right  or  left.  It  should 
be  sought  by  directing  the  patient's  Ime  of  sight  throughout  the 
entire  lateral  and  vertical  range  of  ocular  movement.  In  seventeen  per 
cent,  of  cases  Uhthoif  found  paretic  conditions  of  the  extrinsic  eye-mus- 
cles. These,  like  the  hemiplegic  features,  are  usually  transient.  They 
may  constitute  a  complete  external  ophthalmoplegia,  or  be  confined  to  any 
of  the  motor  oculi  nerves,  or  to  portions  of  the  third  cranial  pair.  They 
are,  as  a  rule,  bilateral  and  affect  the  associated  movements,  showing  their 
nuclear  nature.  The  nystagmus  is  of  a  similar  nature,  and  probably 
due  to  the  disturbed  muscular  balance. 

The  pupils  may  show  miosis,  inequality,  and  diminished  reflexes  to 
both  light  and  accommodation,  but  the  Robertson  pupil  is  practically 
unknown,  and  miosis  is  usually  associated  with  an  exaggeration  of  the 
light  reflex. 

The  optic  nerve  is  very  frequently  affected  and  vision  is  often  modi- 
fied. The  papilla  may  show  optic  neuritis  or  atrophy,  but  the  atrophy 
is  very  seldom  extreme,  and  the  disc  usually  retains  some  color  in  a  part 
of  its  expanse.  Some  papillary  modification  is  found  in  over  one-half 
of  all  cases,  and  some  cases  showing  no  changes  in  the  nerve-head  still 
present  visual  defects.  Vision  may  be  slowly  or  rapidly  reduced  and 
blindness  may  follow,  but  the  amblyopia  is  ordinarily  transitory,  and  a 
1  "Deut.  Arch.  f.  klin.  Med.,"  Bd.  Ixviii,  No.  1  u.  2. 


MULTIPLE  CEREBROSPINAL  SCLEROSIS.  465 

considerable  degree  of  sight  is  frequently  restored.  Central  scotomata, 
irregular  or  regular  retraction  of  the  field,  dyschromatopsia,  particularly 
for  red  and  green,  may  be  variously  combined  in  the  field,  and  in  these 
respects  the  ocular  disturbances  are  rarely  symmetrical  and  may  be  en- 
tirely unilateral.  They  may  be  of  insidious  or  rapid  development  and 
may  be  early  or  late  manifestations  of  the  disease.  They  bear  a  rough 
relation  to  the  intensity  of  other  symptoms  and  often  increase  corre- 
spondingly with  them. 

Visceral  disturbances  are  insignificant  in  insular  sclerosis.  Rectal 
and  vesical  incontinence  or  retention,  gastric  crises,  and  other  similar 
manifestations  of  organic  disease  of  the  cord  are  sometimes  encountered, 
but  are  not  severe  in  degree  or  constant  in  a})pearance. 

Trophic  disturbances  are  unusual.  Loss  of  nails,  gluteal  decubitus, 
and  localized  wasting  of  muscles,  particularly  of  the  interosseous  mus- 
cles of  the  hand,  have  been  met  with. 

Bulbar  Symptoms. — Difficulty  in  swallowing  and  in  mastication, 
trembling  of  the  tongue,  inability  to  protrude  it,  glycosuria,  and 
polyuria  are  occasionally  encountered,  and,  with  the  other  bulbar  symp- 
toms already  noted,  point  to  the  location  of  sclerotic  patches  in  that 
region. 

Cerebral  Features. — Among  the  most  characteristic  symptoms  of 
multiple  sclerosis  is  the  speech  defect.  This  is  very  commonly  present 
and  consists  of  a  slow,  monotonous,  scanning  pronunciation  that  slights 
no  syllable  and  ends  abruptly,  spasmodically,  explosively  with  the  last. 
It  sometimes  causes  elision  of  the  final  sounds  or  every  syllable  may  be 
slurred.  There  is  a  distinct  eifort  to  articulate  each  sound  with  rests 
between.  This  staccato  speech,  in  marked  cases,  is  well  marked,  but 
in  some  instances  it  may  lack  some  of  its  features  or  entirely  default. 
Its  mechanism  is  of  difficult  explanation,  but  is,  at  least  in  some  cases, 
attributable  to  faulty  action  in  the  articulative  muscles. 

Vertigo  is  sometimes  present  and  may  disturb  the  patient  at  rest  or  in 
walking.  In  some  cases  the  nystagmus  causes  objects  to  dance  before 
the  eyes  ;  in  others,  with  ocular-muscle  paresis,  there  is  diplopia,  both 
of  which  may  cause  vertigo.  In  rare  instances  the  vertigo  presents 
Meniere's  type.  The  apoplectiform  and  epileptiform  attacks  that  have 
been  already  incidentally  mentioned,  spasmodic  laughter  and  crying  and 
slight  mental  enfeehlement,  with  indifference  and  dejection,  indicate  cerebral 
lesions.  In  rare  cases  an  expansive,  egotistic  delirium  of  grandeur 
may  appear  closely  resembling  that  of  paretic  dementia,  and  complete 
dementia  may  ensue. 

Hoffman,  1  in  the  100  cases  on  which  he  based  his  study,  found 
speech  difficulties  in  54,  giddiness  in  64,  headache  in  40,  optic  atrophy 
in  50,  nystagmus  in  56,  intention  tremor  in  71,  paresthesise  in  QQ,  and 
objectively  disturbed  sensation  in  28.  The  sexes  were  about  equally 
represented  by  47  women,  53  men. 

Course  and  Forms. — The  onset  may  occur  abruptly  by  an  apoplec- 
tiform attack,  followed  immediately  by  hemiplegic  or  paraplegic  or 
monoplegic  weakness,  or  these  may  suddenly   appear  without  the  con- 

^  Loc.  cit. 
30 


466  DISEASES   OF  THE   GENERAL   KEEVOUS  SYSTEM. 

vulsive  attack.  In  other  instances  vertigo  or  visual  disturbance  sud- 
denly opens  the  program.  ]\Iore  frequently  the  onset  is  gradual  and 
the  course  progressive.  Difficulty  in  walking  or  in  speaking  or  the 
trembling  is  first  noticed  and  gradually  increases,  leading  in  the  other 
prominent  features  of  the  malady.  Sometimes  the  initial  feature  con- 
sists of  attacks  of  pain  of  a  stabbing,  lancinating  variety.  The  advance 
of  the  disease  may  be  chronically  progressive,  or  it  may  show  exacer- 
bations or  remissions,  and  continue  finally  to  advance.  Sometimes  the 
amelioration  is  permanent  and  recovery  is  possible.  In  progressive 
cases  death  may  result  from  intercurrent  maladies,  from  an  apoplecti- 
form attack,  from  bulbar  accidents,  or  from  the  exhaustion  of  terminal 
dementia. 

The  duration  of  the  disease,  like  its  anatomical  basis  and  its  symp- 
toms, is  very  variable.  It  may  reach  full  development  within  a  few 
months  or  a  year,  rarely  almost  at  a  bound.  It  may  terminate  in  a 
year,  last  twenty,  or  recede  completely  at  any  time. 

In  some  instances  only  one  or  a  few  of  the  most  notable  symptoms 
of  the  disease  ever  develop.  These  cases  constitute  the  formes  frustes 
of  Charcot.  Thus  the  trembling,  or  the  speech  defect,  or  the  gait  with 
or  without  nystagmus,  or  bulbar  symptoms  and  amyotrophy  may  pre- 
dominate, while  other  symptoms  are  only  very  slightly  developed. 

Diagnosis. — In  a  well-developed  case  the  diagnosis  may  be  made. 
The  intention  tremor,  cerebellospasmodic  gait,  spastic  weakness,  nystag- 
mus, and  syllabic  speech  make  a  positive  picture.  The  differentiation 
from  family  ataxia  may,  however,  present  great  difficulty  ^vhen  several 
members  of  the  same  family  are  affected  with  multiple  sclerosis.  Fried- 
reich's disease  is  marked  by  flaccidity  and  abolished  knee-jerks,  the 
motor  difficulty  is  purely  ataxic  and  never  spasmodic,  and  optic-nerve 
symptoms  are  practically  always  absent.  In  the  heredocerebellar  type 
of  family  ataxia  there  are  increased  reflexes  and  often  optic  atrophy,  but 
a  long  family  succession  of  cases  rarely  fails  us,  and  the  motor  difficulty 
here  again  is  devoid  of  spasticity  and  is  purely  ataxic.  In  neither  type 
do  we  find  the  well-developed  syllabic  speech  nor  the  intention  tremor, 
though  the  speech  is  modified  and  ataxic  and  there  are  choreic  move- 
ments which  might  at  first  mislead.  Cases  clinically  mistaken  for  amy- 
otrophic lateral  sclerosis  have  been  recently  reported  by  Probst  and 
Brauer,  one  for  transverse  myelitis  by  Siemerling,  and  one  for  a  Brown- 
Sequard  paralysis  by  Jeremias. 

Hysteria  is  capable  not  only  of  mimicking  every  objective  symptom 
of  insular  sclerosis,  but  sometimes  is  associated  with  it  in  the  same 
patient.  It  should  never  be  out  of  mind  in  making  the  diagnosis,  and 
the  stigmata  of  the  neurosis  should  be  faithfullv  souo;;ht  in  everv  instance. 
Cases  showing  hysterical  signs  and  the  symptoms  of  multiple  sclerosis, 
according  to  Buzzard,^  should  be  looked  upon  as  probably  organic  if  the 
tendon  reflexes  are  exaggerated  and,  at  the  same  time,  the  plantar  reflex 
is  abolished.  This  observer  has  noted  optic  atrophy  in  one-half  of  his 
cases  of  insular  sclerosis,  and  found  Babinski's  toe-sign  in  all  in  which 
it  has  been  sought. 

In  the  partial   cases,  mainly  marked  by  one  of  the  prominent  cliar- 
1  "  Brit.  Med.  Jour.,"  May  6,  1899. 


SYPHILIS   OF   THE  NERVOUS  SYSTEM.  467 

acteristics  of  multiple  sclerosis,  the  diagnosis  is  decidedly  difficult.  In 
every  such  instance  all  the  features  of  insular  sclerosis  should  be  sought, 
and  some  of  them,  if  only  partially  developed,  will  be  found  to  fix  the 
diagnosis,  or  the  presence  of  signs  of  other  diseases  will  guide.  When 
trembling  ])redominates,  we  must  exclude  paralysis  agitans,  metallic 
intoxications,  chorea,  and  hysteria.  When  the  speech  defect  is  most 
prominent,  we  must  think  of  paretic  dementia  and  the  family  ataxias. 
In  cases  showing  a  predominance  of  cerebellar  ataxia  intracranial  tumors 
and  the  family  ataxias  must  be  excluded.  When  the  gait  is  purely 
spastic,  we  must  exclude  transverse  myelitis  and  the  combined  scleroses 
of  the  cord. 

Prognosis. — While  the  outlook  in  a  case  of  multiple  sclerosis  is 
always  grave,  the  tendency  to  remissions  and  the  occasional  complete 
recession  of  the  disease  make  it  distinctly  more  hopeful  than  in  the 
destructive  sclerotic  lesions  of  tabes  and  cross-myelitis.  It  is  impossible 
in  a  given  case  to  forecast  its  probable  course  so  long  as  it  is  progress- 
ing. Apoplectiform  seizures  followed  by  paralytic  features  and  aggra- 
vation of  all  the  symptoms  may  occur  at  any  moment ;  but  when  the 
disease  has  shown  remission  and  improvement  we  are  justified  in  hop- 
ing, with  due  reservation,  for  better  things. 

Treatment. — In  every  case  the  nature  of  the  origin  of  the  malady 
will  guide  therapeutics.  If  the  disease  is  to  be  considered  as  mainly 
due  to  infections  and  to  the  continuous  activity  of  microbic  life,  which 
from  time  to  time  leads  to  new  plaques  or  increases  old  foci,  bactericidal 
preparations  are  indicated — quinin  in  malaria ;  mercury,  iron,  arsenic, 
and  salicyl  preparations  in  other  septic  conditions.  Generally  speaking, 
an  antisepticemic  regime  is  in  order.  This  may  only  be  valuable  when 
the  general  resistive  powers  of  the  economy  are  increased  by  the  best 
hygienic  and  general  health  measures.  The  future  may  furnish  some 
organic  antitoxin  more  powerful  than  our  present  medicaments. 


CHAPTER   II. 
SYPHILIS  OF  THE  NERVOUS  SYSTEM. 

The  syphilitic  lesions  of  the  nervous  system,  especially  of  the  cen- 
tral apparatus*,  are  of  extreme  frequency  and  of  almost  infinite  variety. 
In  this  section  little  more  can  be  attempted  than  an  enumeration  of 
them,  with  special  reference  to  clinical  peculiarities  and  the  most  effica- 
cious mode  of  treatment. 

Syphilitic  nervous  disease  may  be  divided  into  (1)  those  due  to  the 
active  ravages  of  the  virus  and  (2)  those  which  follow  the  infection  and 
are  not  marked  by  neoplastic  products.  The  one  is  specific,  the  other 
'parasyphilitic.  The  first  is  microbic,  the  second  toxic  or  chemical.  Such 
a  view  of  luetic  lesions  and  consequences  gives  us  the  best  working 
basis  at  the  present  time.  Syphilis  is  capable  of  transmission  to  off- 
spring in  either  form,  and  we  have  some  hereditary  syphilitic  diseases 


468 


DISEASES  OF   THE   GENERAL  NERVOUS  SYSTEM. 


of  the  general  nervous  system  marked  by  the  ordinary  gummatous 
processes,  and  others  due  solely  to  faults  of  nutrition  and  toxic  action. 
Again,  both  the  syphilitic  and  parasyphilitic  lesions  may  be  present  in 
the  same  individual  at  the  same  time  or  at  different  periods.  The  fol- 
lowing tabulation  may  serve  to  systematize  the  subject : 


o 
> 

< 

Ed 


w 


CO 


OQ 


Active  specific 
lesions 


Cerebrospinal 

syphilis,   acquired 

and  hereditary 

(early  and  tardy) 


Syphilis  of  nerves. 


Parasyphilitic 
diseases 


Acquired 


Hereditary 


-^^    r  Meningitis    ]   ^^^^^j 

%   \    \   *     -fc  f  ^lelancholia 

o       ^^  ®'^^,.  Pseudoparesis 

'S       Meningomj'elitis 

•5   J   Myelitis 

m       Spinal  paraplegias 

Tabes 

Paretic  dementia 

Neurasthenia 

Hysteria 

Epilepsy 

Neuralgia 

Juvenile  tabes  and  paresis 

Infantilism 

Hydrocephalus 

Cerebral  or  spinal  agenesis 


Specific  lesions  of  the  general  nervous  system,  like  specific  lesions 
elsewhere,  originate  in  the  connective  tissue  or  blood-vessels  and  sec- 
ondarily affect  the  parenchyma,  disturbing  function  first  and  finally 
destroying  the  essential  cells  and  fibers  of  the  part.  Earely  they  arise  in 
bony  structures  and  thence  invade  the  adjoining  nervous  apparatus  or  act 
upon  it  by  pressure.  Their  peculiarity  is  in  the  gummy  plastic  exudate 
and  its  formative  tendency.  It  is  essentially  a  neoplastic  process,  which 
may  vary  from  an  appearance  of  simple  inflammation  to  the  accumula- 
tion of  sizeable  tumors.  In  early  stages  there  is  often  a  marked  ten- 
dency to  regressions  and  recidives.  Old  lesions,  if  of  considerable  size, 
may  caseate  within  and  cicatrize  upon  the  surface  by  fibrous  organiza- 
tion and  fibroid  changes  may  alone  remain  to  indicate  the  preexisting 
gummy  condition. 

Acquired  syphilis  affects  the  central  nervous  system  by  specific 
lesions  in  a  very  considerable  proportion  of  all  luetic  cases.  Hjelmann, 
leaving  out  of  the  question  both  tabes  and  paretic  dementia,  states  that 
from  1|-  to  2|^  per  cent,  of  all  cases  of  syphilis  develop  cerebrospinal 
lesions,  and  that  of  those  presenting  the  tertiary  features  of  the  infec- 
tion, twelve  per  cent,  show  invasion  of  the  cerebrospinal  axis.  Four- 
nier  puts  this  latter  percentage  at  twenty-one.  In  the  great  majority 
of  cases  the  syphilitic  process  is  wide-spread  and  somewhat  haphazard 
in  its  location.  Very  rarely  do  cases  of  spinal  syphilis  lack  evidences 
of  cerebral  involvement  at  some  period,  but  cerebral  syphilis,  on  the 
contrary,  is  sometimes  devoid  of  spinal  complications.  AVe  may,  for 
descriptive  purposes,  divide  these  cases  of  acquired  active  syphilitic 
lesions  into  the  cerebral  and  the  spinal.  Their  common  association 
should  never  be  forgotten. 


SYPHILIS  OF  THE  NERVOUS  SYSTEM. 


469 


CEREBRAL  SYPHILIS. 

Syphilitic  cerebral  meningitis  is  perhaps  the  most  frequent  form 
of  cerebral  syphilis,  and  usually,  to  some  extent,  complicates  all  other 
varieties  of  encephalic  lues.  The  favorite  location  is  the  basilar  area, 
especially  the  interpeduncular  space,  from  which  it  frequently  extends 
upward  on  to  the  convexity  of  the  parietal,  and  particularly  of  the  frontal, 
lobes.  So  commonly  is  the  base  affected  that,  speaking  clinically  and 
according  to  Charcot,  it  may  never  be  considered  exempt,  even  when 
the  symptoms  point  to  the  convexity  alone.  The  distribution  recalls 
that  of  tuberculosis.  A  gelatinous  transparent  substance  infiltrates  the 
soft  meninges  about  the  circle  of  Willis  and  the  optic  chiasm.  It  is 
composed  of  small,  round,  embryonic  cells,  and  is  very  vascular  and 
viscoid.  Caseation  and  sclerotic  degeneration  mark  the  lesion  later. 
The  adjoining  or  enveloped  nerves  and 
vessels  may  be  injured.  Neuritic  atrophy  on 
the  one  hand  and  obliterating  arteritis  on 
the  other  are  thus  set  up.  Extension  of  the 
process  to  the  nerve-sheaths  and  interstitial 
structure  accounts  for  the  very  frequent 
symptoms  on  the  part  of  the  cranial  nerves 
in  cerebral  syphilis. 

In  the  field  of  syphilitic  meningitis 
gummy  masses,  or  gummata,  are  usually 
encountered.  They  vary  in  size  from  mili- 
ary bodies  to  tumors  as  large  as  filberts, 
which  may  be  solitary,  few,  or  many  in 
number.  Their  favorite  location  is  at  the 
base  or  on  the  convexity,  especially  on  the 
frontal  lobes,  but  no  portion  of  the  brain  is 
exempt.  Sometimes  they  form  on  the  sur- 
face or  in  the  thickness  of  the  dura  mater, 
or  deeply  within  the  brain,  on  some  septal 
infolding  or  penetrating  blood-vessel.  They 
comport  themselves  as  do  brain-tumors  generally,  and  give  rise  to  similar 
localizing  signs  and  symptoms.  Sclerous  or  fibrous  degeneration  marks 
the  later  stages  of  all  these  specific  neoplastic  lesions,  and  gives  rise  to 
what  is  sometimes  called  sclerous  syphilitic  meningitis. 

Syphilitic  cerebritis  may  exist  as  a  direct  extension  from  a  specific 
meningitis  or  gumma,  or  may  occur  more  or  less  independently.  It  may 
present  itself  as  a  diffuse,  gummatous  encephalitis,  or  as  localized  en- 
cephalic gummata  which  tend  to  caseate,  or  it  may  appear  in  circum- 
scribed patches  or  plaques,  especially  in  the  pontine  and  peduncular 
surfaces,  which  may  end  in  sclerous  patches.  Every  syphilitic  process 
in  the  brain  entails  a  surrounding  zone  of  cerebral  softening  or  cerebritis. 

Syphilitic  Cerebral  Arteritis. — Syphilitic  endarteritis  in  the  brain 
is  a  comparatively  common  accident.  It  may  result  in  the  oblitera- 
tion of  the  large  basilar  vessels   secondarily  to  a  gummatous  meuin- 


Fig.  208.— Ocular  palsy  in  a  case 
of  brain  syphilis  in  which  at  one 
time  there  was  a  crossed  hemiplegia, 
right  face  and  left  extremities.  The 
right  eye  overacts,  turning  upward 
and  outward  in  looking  to  the  right. 


470  DISEASES  OF  THE  GENERAL  NERVOUS  SYSTEM. 

gitis,  or  it  may  develop  as  a  primary  focus  of  syphilitic  activity.  Its 
legitimate  result  is  a  localized  ischemia,  which,  if  complete,  results  in 
thrombotic  brain-softening.  Heubner  insists  upon  its  frequency  in  the 
basal  ganglia.  The  middle  cerebral  arteries  are  frequently  affected 
either  in  the  numerous  small  branches  of  the  Sylvian  or  by  the  complete 
obliteration  of  this  motor-zone  vessel. 

It  is  also  established  that  cerebral  hemorrhages  may  follow  a  specific 
arteritis.  This  rarely  occurs  wdthin  the  brain-substance,  but  more  often 
takes  place  in  the  large  and  comparatively  unsupported  basilar  vessels, 
resulting  in  a  foudroyant  apoplectic  stroke  almost  immediately  fatal. 

Syphilitic  Lesions  of  the  Cranial  Nerves. — Owing  to  their 
exposed  position  at  the  base,  where  specific  cerebral  invasion  is  most 
common,  the  cranial  nerves  are  very  commonly  implicated.  The  relative 
frequency  with  which  they  are  affected  diminishes  from  the  chiasm  and 
optic  nerves  backward  toward  the  bulb.  The  order  is  as  follows : 
Optic  nerves,  motor  oculi,  abducens,  trifacial,  facial,  auditory,  and  only 
rarely  the  glossopharyngeal,  vagus,  and  hypoglossus. 

The  motor  oculi,  or  third  nerve,  is  affected  in  about  forty  per  cent, 
of  the  cases,  and  shows  a  particular  vulnerability  on  the  part  of  the  fibers 
supplying  the  levator  of  the  upper  lid.  Hence  the  frequency  and  sig- 
nificance of  ptosis.  Inequalities  of  the  pupil  and  pupillary  stasis  are  of 
equal  importance  and  frequency.  A  rigid  pupil  should  always  raise  a 
suspicion  of  syphilis.  It  is  to  brain-syphilis  what  the  Robertson  pupil 
is  to  tabes.  Referable  to  the  affection  of  the  chiasm  and  optic  nerves 
and  tracts  we  find  all  forms  of  irregular  and  unequal  contractions  of  the 
visual  fields.  Optic  neuritis  is  very  frequently  present  and  atrophy 
may  result.  The  trifacial  may  be  involved  in  one  or  all  its  branches, 
causing  disturbed  sensibility  sometimes,  but  more  frequently  neuralgic 
pains  of  corresponding  distribution.  Infrequently  facial  palsy  is  en- 
countered, and  in  rare  cases  this  is  associated  with  deafness  on  the 
same  side. 

The  amount  of  injury  to  a  nerve  varies  within  wide  limits,  but  often 
presents  the  suggestive  peculiarity  of  advance  and  recession,  giving  rise 
to  temporary,  fugaoeous  palsies  and  temporary  sensory  features,  such  as 
amblyopia,  lasting  a  day  or  two.  After  several  such  attacks  the  dis- 
ability is  likely  to  persist  permanently  and  indicates  a  destructive  change 
in  the  nerve,  which  commences  as  an  interstitial  infiltration  and  neuritis. 

The  general  symptoms  of  cerebral  syphilis  are  modified  by  the 
particular  lesions  that  are  present.  These,  as  a  rule,  are  multiform,  but 
with  special  prominence  of  certain  features.  One  case  attracts  most 
attention  by  its  eye  symptoms,  another  by  its  neuralgic  pains,  another 
by  its  convulsive  manifestations,  another  by  its  stupor  or  mania  or 
paralysis. 

There  is  always,  or  nearly  always,  an  initial  period — a  premonitory 
period — that  it  is  ol  the  greatest  importance  to  recognize.  Then  only 
does  medication  offer  a  fair  chance  of  effecting  a  cure.  Once  passed, 
irreparable  damage  is  done,  and  the  best  that  can  be  hoped  is  to  check 
further  mischief  and  leave  the  brain  and  nerves  scarred  with  cicatricial 
tissue.     Brain-syphilis  appears,  ordinarily,  during  the  secondary  period, 


SYPHILIS  OF  THE  NERVOUS  SYSTEM.  471 

but  may  occur  at  any  date  after  the  first  few  months.  Thus  the  first 
year  shows  the  greatest  number  of  cases,  which  diminish  gradually,  year 
by  year,  to  the  end  of  life.  There  is  no  period  of  exemption  after  infec- 
tion. Cases  of  brain-syphilis  are  encountered  twenty,  thirty,  and  forty 
years  after  the  initial  sore,  and  probably  many  syphilized  individuals  die 
from  other  causes  and  thereby  escape  luetic  brain  accidents.  If  ter- 
tiary manifestations  appear,  the  likelihood  of  the  occurrence  of  brain- 
syphilis  is  increased.  It  is  important  to  know  that  a  blow  or  jar  to  the 
skull  may  precipitate  and  focalize  syphilis  in  the  brain,  and  may  greatly 
aggravate  it  when  present.  The  same  is  true  of  mental  shock  and  fright. 
The  phenomena  of  the  premonitory  stage  consist  of  headaches,  disturb- 
ances of  sleep,  mental  changes,  and  j^hysical  decline. 

The  headache  in  its  typical  form  is  atrocious  in  severity,  often  cir- 
cumscribed, and  deeply  seated.  It  is  frequently  marked  by  local  ten- 
derness on  percussion  and  shows  daily,  usually  nocturnal,  exacerbations. 
The  syphilitic  headache  may  remit  without  apparent  cause,  or  an  ex- 
acerbation may  be  followed  by  a  ptosis  or  an  amblyopia,  or  it  may  ter- 
mmate  upon  the  appearance  of  a  hemiplegia  or  other  serious  secondary 
brain-lesion.  Usually  the  only  sedative  capable  of  controlling  it  is 
morphin,  but  it  yields  in  a  few  days  to  either  mercury  or  the  iodids. 
While  the  headache  is  mainly  vesperal  or  nocturnal,  in  some  instances  it 
is  most  severe  in  the  morning  and  some  trace  of  it  usually  lasts  through- 
out the  twenty- four  hours.  Commencing  in  a  localized  area,  it  may 
gradually  invade  the  entire  head,  and  frequently,  if  unchecked  by  proper 
treatment,  lasts  weeks  and  months. 

The  sleep  is  modified  in  two  ways.  There  is  insomnia  or  sopor. 
The  nocturnal  headache  in  itself  may  destroy  sleep  at  night,  but  in 
addition  the  patient  often  fails  to  sleep  after  the  headache  subsides. 
Insomnia  often  occurs  early,  before  the  headache  has  grown  intense. 
Later,  there  is  usually  a  tendency  to  stupor,  and  this  also  may  appear 
early.  The  patient  drops  to  sleep  at  any  time  during  the  day,  at  his 
meals,  over  his  paper  or  desk.  Aroused  at  night  by  the  cephalalgia,  he 
drops  back  into  a  heavy,  stuporous  sleep,  and  often  requires  vigorous 
rousing.  In  a  somnolent  way  he  may  get  up  for  any  purpose  and  at  once 
drop  to  sleej)  on  returning  to  bed.  The  stupor  may  become  continuous 
and  reach  a  comaj:ose  depth. 

Mental  changes  ordinarily  accompany  the  cephalalgia.  The  patient^s 
wits  are  dulled.  He  is  apathetic,  disinclined  for  study,  work,  or  social 
enjoyment.  The  memory  is  frequently  impaired.  He  looks  and  acts 
and  feels  depressed  and  indifferent.  His  ideas  come  slowly  and  he  may 
show  irritability  or  become  greatly  depressed. 

The  general  health  often  fails.  The  appetite  is  commonly  lost  early, 
strength  diminishes,  flesh  is  lost,  and  the  skin  and  mucous  membranes 
grow  pale  and  anemic.  Often  at  this  time  vertigos,  tingling  in  an  ex- 
tremity, inequalities  in  the  pupils,  a  drooping  lid  or  some  twitching  of  a 
limb  indicate  the  impending  storm  and  show  its  direction. 

Special  Symptoms. — After  the  premonitory  period  or  even  from 
the  first  the  disease  shows  one  of  three  major  tendencies,  marked  by 
the  preponderance  of  meningitis,  art&ncd  accidents,  or  tumor  formation, 
respectively.     These  may  be  and  usually  are  variously  combined. 


472  DISEASES  OF  THE  GENERAL  NERVOUS  SYSTEM. 

The  meningeal  form  is  marked  by  extreme  depression  and  torpor. 
The  patient  lies  like  one  narcotized  or  stupefied  with  alcohol.  At  times 
he  can  be  roused  to  answer  in  monosyllables,  but  promptly  subsides  into 
the  lethargic  state  and  may  become  unconscious  and  comatose  for  a  few 
moments,  for  an  hour,  or  for  several  days.  When  he  talks  it  is  in  an 
uncertain  and  unreliable  way.  Frequently  there  is  a  little  delirium. 
His  headache  alone  seems  to  cause  him  trouble.  Usually  pupillary 
sluggishness  and  inequality  are  present,  ptosis  and  squints  are  frequent, 
and  diplopia  sometimes  admitted.  There  may  be  urinary  incontinence 
or  retention.  Fever  is  ordinarily  absent  and  the  physical  functions  are 
well  carried  on.  Death  rarely  results  from  this  form  of  cerebral  syphilis, 
but,  on  the  other  hand,  complete  recovery  is  equally  rare.  Some  trace 
in  the  way  of  mental  apathy  is  likely  to  persist.  In  exceptional  instances 
there  is  wild,  maniacal  delirium  and  motor  excitement,  an  elevated  tem- 
perature, and  quickened  pulse. 

The  Arterial  Form. — Cerebral  syphilitic  arteritis  is  usually  accom- 


Fig  209  —Brain  showing  basilar  syphilitic  meningitis,  with  generalized  exudate  and  small  cysts  in  the 
deeper  furrows  (Dr.  W.  A.  Jones). 

panied  by  basilar  specific  meningitis  and  the  premonitory  headache. 
Cranial-nerve  symptoms  are  also  usually  present.  It  gives  rise  to 
thrombus  and  cerebral  softening,  resulting  in  hemiplegia  or  monoplegia, 
or  aphasia  or  other  localized  cortical  disability.  Usually  this  does  not 
come  on  at  once,  but  by  slight  premonitory  strokes  and  numerous 
"warnings."  Transitory  plegias  and  aphasias  are  always  suggestive 
of  syphilis.  When  the  motor  cortex  is  involved,  spasm  or.  partial 
epilepsies  are  commonly  induced.  The  rule  applies  here,  as  in  gum- 
mata,  that  epileptic  seizures  after  the  age  of  thirty  are  generally  due  to 
syphilis,  and  that  paralytic  seizures  in  adults,  before  the  age  of  forty,  in 


SYPHILIS  OF  THE  NERVOUS  SYSTEM.  473 

the  absence  of  cardiac  and  renal  lesions,  are  almost  invariably  syphilitic. 
Another  indication  of  syphilis  is  a  multiplicity  of  lesions.  A  double 
hemiplegia  or  left  hemiplegia  with  aphasia  or  pseudobulbar  palsy  from 
double-sided  lesions,  or  cerebral  hemiplegia  and  paraplegia  from  brain- 
and  cord-lesions,  in  the  same  case,  speak  for  syphilis. 

Hemorrhage,  as  already  indicated,  is  usually  from  a  large  basal 
vessel  and  is  promptly  fatal.  It  is  commonly  secondary  to  aneurysmal 
degeneration  and  is  a  rare  cause  of  death  in  syphilitics.  Occasionally 
thrombosis,  beginning  in  the  circle  of  Willis,  eventually  reaches  and 
obstructs  the  basilar  artery,  and  death  follows  coma. 

The  gnminatous  form  of  cerebral  syphilis  is  usually  marked  by 
focal  symptoms,  and  here  all  the  rules  of  cerebral  localization  apply. 
As  above  indicated,  the  favorite  location  for  gnmmata  is  at  the  base  and 
upon  the  frontoparietal  convexity,  precisely  the  regions  in  which  focal 
symptoms  arise.  These  consist  of  cortical  states  of  irritation  and  de- 
struction,— in  other  words,  of  limited  epileptic  attacks  and  cortical  palsies, 
and  of  cranial-nerve  lesions.  Usually  the  focal  signs  and  symptoms  in 
gummatous  cases  are  preceded  by  the  premonitory  phenomena.  This 
might  be  expected,  as  the  usual  meningeal  or  cortical  gumma  is  sec- 
ondary in  point  of  time  to  a  more  or  less  diffuse  specific  meningitis.  In 
rare  cases  the  convulsion  is  the  first  manifestation  of  cerebral  invasion. 
Generalized  fits  and  epileptiform  convulsions  are  not  rare  in  diffuse 
cortical  syphilis,  and  may  be  associated  with  the  Jacksonian  attacks, 
petit  mal,  momentary  aphasias,  sudden  "  thickening  of  the  tongue,"  and 
similar  evidence  of  circumscribed  lesions.  Syphilis  also  seems  capable, 
according  to  Fournier,  of  producing  a  parasyphilitic  epilepsy  to  which 
attention  will  be  recalled.  (For  further  details  regarding  cerebral  gnm- 
mata the  reader  is  referred  to  the  chapter  on  Cerebral  Tumors,  page  253.) 

Syphilitic  Mental  Diseases. — The  mental  disturbances  of  brain 
syphilis  are  those  of  organic  brain  disease,  but  in  subjects  strongly  pre- 
disposed to  insanity  the  syphilitic  cachexia  may  induce  ordinary  forms 
of  insanity.  Morbid  mental  states  due  to  the  encephalic  ravages  of  lues 
are  most  frequently  of  the  depressed  varieties  grouped  under  the  generic 
name  of  melancholia,  with  a  decided  tendency  to  dementia.  Less  fre- 
quently there  is  exaltation  and  delirium,  which  may  be  intense,  and  in 
both  forms  hallucinations  are  common.  Signs  of  gross  brain-lesions  are 
rarely  wanting.  Cranial-nerve  symptoms,  localizing  fits,  monoplegic 
palsies,  and  speech  defects  point  the  way  to  diagnosis. 

In  some  instances  symptoms  arise  that  closely  ape  those  of  paretic 
dementia,  and  give  rise  to  the  term  syphilitic  pseudoparesis.  The  differ- 
ential diagnosis  may,  indeed,  be  impossible.  The  features  suggesting 
active  syphilitic  disease,  as  contrasted  with  the  degenerative  changes 
of  paresis,  are  a  less  steadily  progressive  course,  less  expansiveness,  less 
amnesia,  less  speech  difficulty,  absence  of  the  Robertson  pupil,  presence 
of  cranial-nerve  palsies  and  early  monoplegias,  and  improvement  under 
antisyphilitic  treatment.  Syphilophobia  and  hypochondriasis,  arising 
from  the  knowledge  or  fear  of  being  infected,  have  only  an  indirect 
relation  to  the  disease. 

Diagnosis. — The  diagnosis  of  encephalic  syphilis,  when  there  is  a 


474  DISEASES  OF  THE  GENERAL  NERVOUS  SYSTEM. 

plain  history  and  marked  evidences  of  previons  infection,  ordinarily 
presents  no  difficulties.  In  cases  where  such  data  are  lacking,  one  of  the 
nicest  of  diagnostic  problems  is  furnished.  Nocturnal  headaches  of  the 
character  described,  epileptoid  attacks  occurring  after  the  age  of  thirty, 
or  apoplectic  attacks  appearing  before  the  age  of  fifty,  should  at  once, 
singly  or  in  combination,  raise  the  suspicion  of  syphilis.  A  history  of 
any  sort  of  a  genital  sore  strengthens  the  case  ;  and  if,  in  addition,  the 
slightest  secondary  manifestation  can  be  detected  or  recalled  by  intelligent 
cross-questioning,  small  doubt  remains.  It  may  be  stated  that  the  great 
majority  of  cases  of  syphilis  of  the  nervous  system  present  very  slight 
secondaries,  or  these  may  have  entirely  escaped  attention.  Another  indi- 
cation of  syphilis  in  brain  disease  is  a  multiplicity  of  lesions.  Cord  and 
brain  symptoms  in  the  same  patient  are  significant,  as  are  double-sided 
brain-lesions  or  lesions  of  both  base  and  convexity.  The  almost  con- 
stant presence  of  basilar  gummy  meningitis,  with  its  consequent  croj- 
nial-nerve  symptoms,  among  which  are  ptosis,  pupillary  abnormalities, 
and  optic-nerve  disturbances,  often  alone  is  sufficient  to  guide  the  diag- 
nosis. The  mode  of  development  counts  for  something.  In  brain-syph- 
ilis the  onset  is  rarely  sudden,  but  is,  rather,  by  repeated  advances,  with 
remissions.  Fugaceous  palsies  and  fleeting  sensory  losses  are  the  rule 
in  syphilis.  The  phenomena  of  the  premonitory  phase  can  not  be  too 
strongly  insisted  upon.  Sterility  in  male  or  female  should  be  given  a 
certain  weight,  and  repeated  miscarriages  frequently  incriminate  the 
husband.  Finally,  the  therapeutic  ^es^  stands  for  considerable.  If  under 
adequate  alterative  dosage  the  disease  yields  within  a  week,  it  sustains 
the  diagnosis  to  some  degree ;  but  we  must  never  forget  that  in  other 
organic  processes,  even  in  sarcomatous  tumors,  the  iodids  may  cause  a 
notable  remission  in  the  symptoms. 

Prognosis. — The  outlook  is  far  from  favorable,  though  it  is  too  com- 
monly assumed  to  be  so  solely  because  syphilis  is  at  the  bottom  of  the 
cerebral  symptoms.  It  may  be  safely  stated  that  less  than  one-half  of 
the  cases  of  brain-syphilis  completely  recover.  Fournier,  in  90  cases, 
reported  23  unrelieved,  13  improved,  14  died,  and  30  recovered.  Of 
those  recovered,  probably  many  presented  recurrences  later  in  life.  In 
a  general  way  we  may  expect  to  check  the  progress  of  active  syphilitic 
processes  excepting  in  rare  cases  of  a  malignant  and  unmanageable  char- 
acter, where  the  human  organism  can  not  tolerate  a  medication  intensive 
enough  to  permanently  subdue  the  disease.  The  golden  opportunity  is 
in  the  prodromal  stage.  Lesions  that  have  caused  destruction  of  nervous 
tissue,  such  as  results  from  thrombotic  softening,  secondary  degeneration, 
hemorrhagic  disintegration,  and  sclerotic  strangulation,  leave  indelible 
and  irremediable  efiects.  In  view  also  of  the  known  ability  of  syphilis 
to  lie  latent  and  dormant  for  years,  and  its  clinical  remissive  tendency, 
the  wise  physician  will  always  maintain  great  reservation  in  even  the 
most  promising  cases.  Marked  and  prolonged  stupor  and  decided  mental 
disturbance  make  the  expectation  of  complete  restoration  very  slight.  A 
patient  who  has  once  developed  syphilis  of  the  cerebrospinal  apparatus 
is  never  safe  and  must  maintain  medical  supervision,  and  should  undergo 
courses  of  treatment  at  yearly  intervals  as  long  as  life  lasts. 


SYPHILIS   OF  THE  NERVOUS  SYSTEM.  475 

Treatment. — The  treatment  is  the  same  as  that  in  the  spinal  form, 
now  to  be  considered,  and  will  be  detailed  in  that  connection  (page  478). 

SPINAL  SYPHILIS. 

Nearly  if  not  every  case  of  spinal  syphilis  sooner  or  later  presents 
evidences  of  cerebral  invasion,  and  the  diagnosis  of  syphilis  of  the  cord 
often  depends  upon  this  association.  It  is  proposed  in  this  section  to 
mainly  emphasize  the  cord-lesions. 

Syphilis  of  the  spinal  cord  and  membranes  is  somewhat  more 
precocious  in  its  appearance  than  brain-syphilis,  and  most  frequently 
appears  from  the  third  to  the  sixth  month  of  the  syphilitic  history.  It 
then  diminishes  in  frequency  during  the  rest  of  life.  As  within  the 
skull,  spinal  syphilis  is  a  disease  of  the  meninges,  nerve-roots,  and 
blood-vessels.  The  cord-changes  are  invariably  secondary  and,  in  a 
sense,  mechanical.  It  may  involve  any  or  all  of  the  membranes  as  a 
specific  meningitis,  which  sometimes  is  marked  by  gummatous  thick- 
ening and  tumor  formation,  but  much  less  commonly  than  is  the 
case  within  the  skull.  The  nerve-roots  and  pial  vessels  are  frequently 
involved  in  the  specific  meningitis,  which  may  also  extend  to  the  periph- 
ery of  the  cord.  Another  group  of  conditions  arises  from  impairment 
of  the  blood-vessels.  Endarteritis,  endophlebitis,  and  thrombosis  may 
cause  disturbance  of  the  circulation  in  any  part  of  the  cord.  They  may 
cause  softening  and  changes  that  are  clinically  similar  to  a  focal  myelitis, 
or,  by  affecting  the  blood-supply  of  the  posterior  arterial  field,  set  up 
the  changes  in  the  posterolateral  portion  of  the  cord  that  induce  com- 
bined scleroses.  Ordinarily,  spinal  syphilis  is  multiform,  and  a  varied 
picture  is  presented  through  the  implication  of  various  parts  of  the 
cordal  apparatus.  The  matter  is  still  further  complicated  by  the  varia- 
tions in  a  single  case,  which  may  at  different  times  present  great  modi- 
fications. Thus  a  case  beginning  as  meningitis  may  become  a  meningo- 
myelitis,  set  up  a  combined  sclerosis,  and  terminate  by  focal  softening, 
consuming  many  years  in  its  history.  For  descriptive  purposes,  and 
based  upon  clinical  manifestations,  we  may  divide  cases  of  spinal  syphilis 
into:  (1)  Meningitis  and  meningomyelitis,  (2)  acute  myelitis,  and  (3) 
ataxic  paraplegias  or  combined  scleroses. 

Syphilitic  Meningitis  and  Meningomyelitis. — These  furnish  the 
most  habitual  expressions  of  spinal  syphilis.  In  clinical  features  they 
differ  but  little  from  similar  lesions  arising  from  any  other  source.  The 
principal  symptoms  are  pains  and  palsies.  The  jiains  are  onset  feat- 
ures and  are  of  extreme  intensity,  usually  with  a  well-marked  tendency  to 
nocturnal  exacerbation.  They  are  usually  located  in  the  lower  extrem- 
ities, but  with  these  there  is  generally  associated  a  most  intolerable 
rachialgia  in  the  lower  part  of  the  back.  They  are  )'oot  pains  and  may 
be  marked  by  tenderness  along  the  nerve-trunks,  and  even  by  herpes 
and  glossy  skin.  Partial  palsy  of  certain  muscle  groups,  with  disturbed 
sensation  in  the  cutaneous  area  of  identical  innervation,  is  occasionally 
seen,  and  still  further  confirms  the  neuritic  and  root  disturbance. 

The  palsies  are  rarely  complete.  There  is  a  feeling  of  weakness  in  the 


476  DISEASES  OF   THE   GENERAL  NERVOUS  SYSTEM. 

legs,  sometimes  distinctly  greater  on  one  side  than  on  the  other ;  a  para- 
plegic distribution  that  may  ascend  to  any  level,  but  most  frequently 
remains  below  the  waist-line.  In  rare  cases  the  upper  members  are  most 
or  alone  aifected.  In  some  cases  a  pachymeningitis  cervicalis  has  been 
found,  with  its  characteristic  deformities,  and  in  some  such  instances  the 
spinal  portion  of  the  dural  disease  has  been  a  downward  extension  from 
syphilitic  thickening  within  the  skull. 

The  cord  is  frequently  affected,  as  is  shown  by  bedsores,  sphincter 
disturbances,  Brown-Sequard  paralysis,  and  a  tendency  to  spasticity  in 
the  lower  extremities,  which  are  at  first  relaxed  and  enfeebled. 

The  sensory  disorders  usually  open  the  program  and  the  paraplegia  is 
ushered  in  by  a  feeling  of  heaviness  and  clumsiness  in  the  legs.  Usu- 
ally there  are  a  series  of  remissions  and  advances  until  the  spasmodic 
paraplegia  is  finally  established. 

Occasionally,  gummata  form  in  the  meninges  and  give  rise  to  tumor 
symptoms  or  the  Brown-Sequard  syndrome.  Multiple  miliary  gummata 
are  still  rarer. 

In  the  annular  invasion  of  the  cord  the  blood-supply  is  interfered 
with,  both  arteries  and  veins  suffering  from  deformity  and  endothelial 
changes  that  may  lead  to  ischemic  softening  and  hemorrhage.  Com- 
bined scleroses  are  similarly  induced. 

Syphilitic  acute  myelitis,  or  softening,  is  not  a  rare  condition. 
The  best  of  recent  observations  indicate  that  the  origin  is  in  throm- 
botic occlusion  of  blood-vessels,  syphilis  acting  as  any  other  infection, 
or  by  setting  up  a  specific  arteritis  or  phlebitis,  with  or  without  accom- 
panying meningitis.  In  the  softened  area  there  is  commonly  great 
syphilitic  cellular  activity,  and  secondary  hemorrhage  frequently  causes 
a  hematomyelic  condition.  The  favorite  location  for  softening  is  in  the 
gray  substance,  and  tlie  thrombosis  may  extend  to  all  the  vessels  of  a 
considerable  area.  A'^ery  rarely  does  the  lesion  involve  the  entire  cross- 
section.  Secondary  ascending  and  descending  degenerations  naturally 
follow. 

The  symptoms  are  those  of  an  acute  myelitis  :  sudden  onset,  para- 
plegia, corresponding  sensory  disturbances,  sphincteric  incontinence,  and 
spasticity  after  a  few  weeks. 

Syphilitic  Ataxic  Paraplegia. — This  variety  of  spinal  syphilis 
has  been  much  written  about  since  Erb,  in  1892,  called  attention  to  its 
frequency  and  uniformity.  He  proposed  for  it  the  name  of  syphilitie 
spinal  paralysis.  Subsequent  communications  by  Muchin,  Kuh,  Kowa- 
lewski,  and  others  tended  to  give  it  an  autonomy  that  Erb  specifically 
deprecated  in  his  earlier  reports.  Recently  ^  he  asserts  for  it  the  dignity 
of  a  distinct  clinical  type  due  to  primary  changes  in  the  lateral  tracts 
of  the  cord  following  syphilis  in  the  same  sense  that  posterior  sclerosis 
is  post-syphilitic.  Oppenheim,  Brissaud,  Marie,  and  others  have  denied 
its  entity. 

The  condition  is  usually  of  insidious  onset,  developing  in  a  few 
weeks,  months,  or  years.  The  first  symptoms  are  feelings  of  heaviness 
and  paresthesia  in  the  legs,  very  soon  accompanied  by  difficulty  in 
1  "Br.  Med.  Jour.,"  Oct.  11,  1902. 


SYPHILIS   OF   THE  NERVOUS  SYSTEM.  "ill 

emptying  the  bladder  through  spasmodic  action  of  sphincter  and  de- 
trusor. Rigidity  and  spasticity  in  the  legs  soon  develop,  and  the  gait 
shows  them  in  the  dragging  toes,  adducted  knees,  and  uncertain  steps. 
Knee-jerks,  rectus  and  ankle-clonus,  and  the  toe-sign  are  commonly 
well  marked  and  muscular  strength  is  more  or  less  reduced.  Spasticity 
and  a  lack  of  muscular  strength  are  especially  insisted  upon  by  Erb. 
Sensory  disturbances  are  slight  or  entirely  absent,  and  the  disease  is  very 
slowly  progressive  or  inclined  to  be  stationary  or  to  even  improve  under 
treatment  for  syphilis.  It  seldom  reaches  a  stage  of  complete  helpless- 
ness. Often  the  upper  extremities  are  affected  in  a  less  degree,  and 
pupillary  symptoms  are  not  uncommon. 

In  this  outline  it  is  easy  to  see  the  symptoms  of  posterolateral  scle- 
rosis or  ataxic  paraplegia,  or  the  combined  scleroses  (see  p.  444).  The 
condition  may  also  arise  secondarily  from  a  meningomyelitis,  and  it  is 
clearly  due  to  vascular  disturbance  in  the  posterior  arterial  cord-field, 
with  the  ataxia,  spasticity,  and  paraplegia  that  mark  such  lesions. 

Diagnosis. — The  diagnosis  of  spinal  syphilis  is  frequently  of  the 
greatest  difficulty.  Unlike  cerebral  syphilis,  it  has  not  a  characteristic 
premonitory  stage.  The  nocturnal  rachialgia  and  the  advance  and 
retreat  of  the  spinal  symptoms  have  some  significance,  but  a  history  or 
the  evidence  of  syphilitic  infection  has  more  weight  and  the  presence 
of  encephalic  disease  has  most  of  all.  This  last,  as  already  frequently 
stated,  rarely  defaults.  In  the  combined  scleroses  we  must  exclude 
tabes,  which  can  usually  be  done  by  a  tap  on  the  knee  and  an  examina- 
tion for  objective  signs. 

Prognosis. — The  outlook  in  focal  myelitis  is  the  same  as  in  that 
lesion  from  other  causes  than  syphilis,  and  depends  upon  the  amount  of 
damage  to  the  cross-section,  the  vertical  location,  and  the  secondary 
degenerations.  Meningomyelitis  can  frequently  be  held  in  check  and 
offers  a  good  prognosis  if  the  cord  is  only  superficially  injured.  The 
prognosis  of  the  combined  scleroses  is  good  as  to  life,  but  bad  as  to 
complete  recovery. 

Syphilitic  neuritis  is  not  a  common  accident.  In  rare  instances 
the  toxic  condition  may  induce  a  multiple  neuritis.  Cestan  ^  was  only 
able  to  collect  14  cases  from  the  literature,  but  in  minor  degree  it  is 
probably  not  infrequent.  Usually  single  nerves,  as  the  sciatic,  inter- 
costal, or  some  branch  of  the  brachial  plexus,  are  affected,  and  such 
lesions  are  often  bilateral. 

Hereditary  Cerebrospinal  Syphilis. — Hereditary  syphilis  is 
capable  of  provoking  any  and  all  of  the  injuries  of  the  general  nervous 
system  that  follow  the  acquired  infection,  and,  like  it,  is  often  marked 
by  a  multiplicity  of  lesions  in  a  given  case.  These  may  appear  con- 
genitally,  in  the  early  years  of  life,  or  be  tardy  and  postponed  until 
puberty,  or  even  to  the  twentieth  and  thirtieth  year.  The  presence 
or  history  of  other  syphilitic  stigmata,  such  as  Hutchinson's  teeth, 
hydrocephalus,  idiocy,  cachexia,  syphilitic  skin  diseases,  choroiditis,  and 
a  history  of  parental  syphilis,  must  often  be  relied  upon  for  a  diagnosis. 
The  lesions  of  hereditary  syphilis  are  less  amenable  to  treatment  and  of 
worse  prognosis  than  those  of  the  acquired  form. 

1  "  Nouv.  Icon,  de  la  Salpet.,"  1900. 


478  DISEASES  OF  THE  GENERAL   NERVOUS  SYSTEM. 

Treatment  of  Active  Cerebrospinal  Syphilis. — The  moment 
syphilis  of  the  cerebrospinal  apparatus  is  discovered,  or  even  strongly 
suspected,  intensive  treatment  should  be  instituted.  The  diagnosis  of 
brain-syphilis  implies  the  recognition  of  a  critical  condition.  A  num- 
ber of  details  are  important  to  secure  toleration  and  to  maintain  the  pro- 
longed use  of  specifics.  If  the  case  be  urgent, — and  in  view  of  the 
location  of  the  disease  it  invariably  is, — both  iodids  and  mercury  should 
be  used  at  once.  If  the  lesion  is  arterial,  preference  should  be  given 
the  iodid  of  sodium,  as  the  potassium  salts  have  a  tendency  to  increase 
arterial  tension,  and  the  sodium  is  also  usually  better  tolerated.  The 
writer's  plan  is  to  commence  with  20  grains  three  times  a  day,  and  in- 
crease the  dose  10  grains  daily  until,  in  rebellious  or  critical  cases,  100, 
or  even  200,  grains  are  given  at  a  dose.  If  the  remedy  be  taken  in  a 
half  pint  of  milk,  or,  better,  in  carbonated  or  aerated  water,  such  as 
Apollinaris  or  Vichy,  or  even  in  the  common  siphon  Seltzer,  and  after 
meals,  there  is  rarely  any  difficulty  even  with  the  enormous  doses  indi- 
cated. Should  a  diarrheal  tendency  appear,  it  can  be  readily  checked 
with  bismuth  preparations.  Large  doses  of  the  iodids  are  much  less 
likely  to  seriously  disturb  the  patients  than  those  of  7  to  15  grains. 
Mercury  can  be  reliably  exhibited  by  inunctions  of  30  or  60  grains  of 
the  ointment  daily.  Various  portions  of  the  body,  as  the  flanks,  the 
back,  and  the  extremities,  should  be  used  in  rotation  day  after  day.  The 
danger  of  salivation  can  practically  be  eliminated  if  careful  attention  is 
given  to  the  teeth  and  mouth.  The  use  of  mild  antiseptic  preparations, 
such  as  glycozone  or  boric  acid,  applied  with  a  soft  tooth-brush,  and  in 
gargles  after  taking  food,  is  usually  sufficient  if  the  teeth  are  in  good 
order ;  otherwise  a  dentist  should  be  called  in  at  once.  The  chlorate  of 
potassium  pastes  and  dentifrices  are  also  useful. 

The  long-continued  use  of  either  iodids  or  mercury,  singly  or  com- 
bined, is  injudicious.  After  the  first  two  or  three  weeks  the  mercury 
may  be  stopped  and  the  iodid  continued  for  another  three  weeks  at  such 
a  dose  as  the  progress  or  remission  of  the  disease  or  the  patient's  toler- 
ance indicates.  It  should  then  be  discontinued  and  mercury  may  again 
be  employed.  It  is  clinically  proved  that  the  syphilitic  process  can 
gain  such  a  tolerance  for  either  mercury  or  iodid  that  their  specific  effect 
is  lost.  Hence  the  imperative  need  of  intermissions  or  alternations  in 
their  employment.  Personally,  the  writer  does  not  feel  safe  in  the  treat- 
ment of  these  cases  without  the  use  of  both  remedies.  By  alternation 
they  seem  to  be  mutually  helpful. 

If  the  case  progress  favorably,  the  iodid  for  six  weeks  and  the 
mercury  for  three  weeks  may  be  alternated  in  full  doses  for  six  months. 
Thereafter  the  patient  should  have  a  course  of  iodid  and  mercury  every 
six  months  for  five  years,  and  finally  once  every  year  for  the  rest  of  life. 
Any  reappearance  of  syphilitic  activity  should  call  for  an  immediate 
return  to  the  intensive  treatment. 

In  fighting  syphilis  w^e  should  never  forget  the  patient.  At  times 
all  specifics  must  be  withdrawn  and  the  general  system  built  up.  This 
is  sometimes  necessary  where  the  limit  of  toleration  appears  to  be 
reached  and  the  symptoms  of  specific  activity  are  still  progressing. 
Supportive  measures  are  indicated  at  all  times.     Ferruginous  tonics,  a 


SYPHILIS   OF  THE  NERVOUS  SYSTEM.  479 

liberal  diet,  massage,  salt  baths,  and  frictions  are  all  valuable.  The  use 
of  large  quantities  of  drinking-water,  hot  or  cold,  and  the  employment 
of  hot  baths,  or  Turkish  baths,  if  they  can  be  borne,  are  of  assistance 
and  often  enable  the  use  of  larger  doses  of  specifics  than  could  other- 
wise be  exhibited.  Here  arise  the  benefits  of  thermal  springs  and 
similar  resorts,  at  which,  in  addition,  the  patient  is  often  freed  from 
domestic  and  business  worries. 

In  place  of  inunctions,  sometimes  the  oral  or  hypodermic  adminis- 
tration of  mercur}^  may  be  used,  or  plasters  may  be  employed.  Their 
reliability  and  efficiency  are  open  to  some  misgivings,  except  in  the  case 
of  injections.  In  cases  of  great  urgency  injections  should  always  be  em- 
ployed at  first.  Bichlorid  of  mercury  in  doses  of  J^-  to  -^  of  a  grain 
may  be  injected  into  the  muscles  daily  to  secure  prompt  eifects.  The 
formula  of  Lambkin  ^  has  served  well  in  a  number  of  cases  of  cerebral 
and  cord  syphilis  and  in  controlling  the  active  syphilitic  processes  in 
tabes.  Unlike  injections  of  calomel  and  other  insoluble  salts,  it  rarely 
gives  rise  to  local  ulceration.  It  consists  of  one  part  of  metallic 
mercury,  one  part  lanolin,  and  one  part  of  two  per  cent,  carbolized 
olive  oil,  carefully  triturated  and  sterilized  on  the  water-bath.  The 
dose  is  five  to  ten  minims  once  a  week  into  the  muscles  of  the 
buttocks  or  loins,  but  there  is  decided  danger  of  producing  salivation. 
Mercurial  baths  are  also  available.  Occasionally,  the  alterative  vege- 
table compounds  will  be  found  valuable  when  mercury  and  iodids  appear 
to  have  been  exhausted.  Slight  looseness  of  the  bowels  does  not  con- 
traindicate  mercury,  nor  acne  mean  iodism.  The  slightest  tenderness 
in  the  gums  should  lead  to  the  immediate  and  complete  cessation  of  mer- 
cury, to  the  use  of  which,  with  caution,  the  physician  may  usually  return 
in  a  week. 

The  results  of  cerebrospinal  syphilis  in  the  way  of  plegias  and  nerve- 
atrophies  require  the  same  management  as  when  arising  from  other  causes. 

THE  PARASYPHILITIC  DISEASES. 

Aside  from  the  ordinary  luetic  lesions  of  the  brain  and  spinal  cord, 
there  is  the  long  list  of  parasyphilitic  diseases.  These  are  not  marked 
by  round-cell  invasion  and  gummy  process,  nor  are  they  directly  amen- 
able to  specific  medication.  They  seem  to  be  attributable  to  the  toxic 
or  chemical  properties  secondary  to  active  infection,  and  may  develop 
hereditarily,  or,  as  is  more  commonly  the  case,  follow  acquired  syphilis. 
A  brief  consideration  is  all  that  is  required  here,  as  they  are  individually 
dealt  with  elsewhere. 

Acquired  Parasyphilitic  Diseases. — Chief  among  these  are  tabes 
and  i^aretic  dementia,  which  are  practically  always  postsyphilitic  acci- 
dents. In  the  cachexia  of  lues  the  general  physical  depravity  furnishes 
a  favorable  soil  for  the  development  of  neuralgia,  hysteria,  and  neuras- 
thenia, which  do  not  diifer  from  the  same  neuroses  arising  independently 
of  syphilis,  but  they  are  benefited  or  cured  by  the  removal  of  the  spe- 
cific cachexia.  They  are  usually  attended  by  considerable  mental  de- 
pression, the  mental  equivalent  of  the  muscular  asthenia. 
1  "  Brit.  Med.  Jour.,"  Feb.  19,  1898. 


480  DISEASES  OF  THE   GENERAL   NERVOUS  SYSTEM. 

According  to  Foiirnier,i  in  addition  to  the  epileptoid  manifestations 
of  cortical  invasion,  there  is  an  epilepsy  peculiar  to  syphilitics.  Its  char- 
acteristics he  outlines  as  follows  :  (1)  It  is  unattended  by  other  evidence 
of  cerebral  disease  ;  (2)  it  continues  unchanged  ;  (3)  it  is  of  long  dura- 
tion, even  lasting  the  lifetime ;  (4)  it  is  not  amenable  to  antisyphilitic 
remedies  ;  (5)  the  bromids  have  little  control  over  it.  Its  onset  is  abrupt 
and  usually  in  the  form  of  a  full  epileptic  seizure,  without  prodromata 
or  inciting  causes,  and  it  often  continues  in  the  form  of  petit  mal,  grand 
mal,  or  a  varying  association  of  both.  The  attacks  are  commonly  fre- 
quent during  the  first  two  or  three  years,  after  which  they  appear  at 
long  intervals  only.  Confirmation  of  this  doctrine  is  lacking  as  yet, 
but  cases  corresponding  to  the  outline  are  not  extremely  rare. 

Hereditary  Parasyphilitic  Diseases. — In  this  category  can  cer- 
tainly be  placed  the  rare  cases  oi  juvenile  tabes  and  paretic  dementia.  In ' 
addition  all  variations  of  deficient  vitality  and  defective  growth  may  be  due 
to  parental  syphilis.  Notably  traceable  to  that  source  are  infantilism, 
mental  defects,  idiocy,  hydrocephalus,  and  various  cerebral  and  spinal 
agenetic  states. 

^  "  Les  Affections  Parasyphilitiques, "  Paris,  1894. 


PART  VII. 

DISEASES  OF  THE  NERVOUS  SYSTEM  WITHOUT 
KNOWN  ANATOMICAL  BASIS. 


A  LARGE  number  of  diseases  clearly  related  to  the  nervous  system 
and  manifested  on  its  part  by  disturbance  of  functional  control  are  not 
marked  by  known  changes  in  the  neural  apparatus.  They  are  denomi- 
nated neuroses  or  functional  nervous  diseases.  It  is  better  to  avoid  the 
term  functional,  as  it  tends  to  distract  attention  from  the  probably  exist- 
ing anatomical  basis  of  these  diseases.  There  is  little  doubt  that  sooner 
or  later  they  will  be  histologically  classified.  The  present  arrangement 
is  for  utility  only.  The  following  table  serves  to  group  the  neuroses  for 
descriptive  purposes. 

NEUROSES. 

f  Acromegalia, 
Pulmonary  osteo-arthropathy, 

j   Hyperostosis  cranii, 
Myxedema, 
Exophthalmic  goiter, 
Scleroderma, 
Eaynaud's  disease. 
Acroparesthesia, 
Intermittent  limping, 
Angioneurotic  edema. 
Localized  hypertrophies. 
Tetanus, 
Tetany, 
Hydrophobia, 
Chorea. 

Huntingdon's  disease, 
Myoclonia, 
Dubini's  disease, 
Parkinson's  disease, 
Thom sen's  disease. 
Writers'  cramp. 
Occupation  spasms,  etc. 
Neurasthenia, 
Hysteria, 
Epilepsy, 
Migraine, 
Tics. 


II. 


Trophoneuroses. — Marked  by  trophic  | 
faults  and  changes  in  physical  coufor-  -{ 
mation. 


Infection  Neuroses. — Mainly  marked 
by  motor  disturbance. 


III.  Motor  Neuroses. 


IV.  Fatigue  Neuroses. 


V.  Psychoneuroses. 


VI. 


Neuroses  Following  Traumatism. 
31  481 


482  XEUEOSES. 


CHAPTER  I. 
TROPHONEUROSES, 

In  the  group  of  neuroses  marked  by  disturbances  of  nutrition  some 
abnormality  of  the  vasomotor  control  is  commonly  present.  This  may 
furnish  nearly  the  entire  symptomatology,  as  in  angioneurotic  edema, 
Raynaud's  disease,  and  exophthalmic  goiter.  In  other  instances  the 
vascular  element  is  apparently  small,  and  the  processes  of  nutrition  are 
principally  disordered.  The  relation  of  nutrition  to  vascularity-,  how- 
ever, is  always  intimate.  We  can  not  as  yet  positively  say  through 
what  individual  strand  of  fibers  trophic  control  is  maintained,  but  it  must 
be  in  close  touch  functionally  with  the  vasomotor  nervous  apparatus. 


ACROMEGALIA. 

In  1886  P.  Marie  ^  called  attention  to  two  cases  presenting  acquired 
symmetrical  enlargement  of  the  hands,  feet,  and  face,  and  proposed  the 
name  acromegalia,  which  has  now  become  current.  His  description  of 
these  cases  was  so  full  that  little  has  since  been  added  to  the  clinical 
side  of  it.  Similar  cases  were  at  once  recognized  all  over  the  world. 
In  1892  Collins  ^  was  able  to  collect  about  ninet}"  cases  from  literature. 
Since  then  the  material  has  rapidly  increased,  and  many  autopsies  have 
been  put  on  record. 

Etiology. — The  causation  of  the  disease  is  extremely  obscure. 
Alleged  or  supposed  inciting  causes  are  almost  as  numerous  as  recorded 
cases,  and  embrace  well-nigh  every  ordinary  and  exceptional  experience 
of  human  life  ;  consequently,  no  importance  at  present  attaches  to  any 
of  them.  Both  sexes  are  about  equally  affected.  The  disease  makes 
its  appearance  customarily  between  the  ages  of  eighteen  and  thirty. 
Exceptional  cases  have  developed  in  advanced  life  and  others  in  child- 
hood. Several  have  appeared  so  early  that  they  have  been  considered 
congenital.  It  has  been  found  in  association  with  tabes,  syringomyelia, 
rachitis,  gigantism,  exophthalmic  goiter,  goiter,  and  various  psychoses. 

Klebs,  impressed  by  his  first  case  in  which  the  thymus  gland  per- 
sisted, and  Erb  by  the  area  of  sternal  dullness  in  other  cases,  were  dis- 
posed to  consider  the  changes  in  the  bones  and  soft  parts  as  duetto  a 
thymic  angiomatosis.  Later  cases  failed  to  present  the  enlarged  thymus, 
and  the  sternal  dullness  is  probably  sometimes  due  to  thickening  of  the 
bone  itself.  Some,  with  Freund,  have  attributed  the  somatic  changes  of 
acromegalia  to  inversion  in  the  evolution  of  genital  life.  Recklinghausen 
considered  it  an  angioneurosis  dependent  upon  central  changes.  These 
changes  are  not  found,  and  angiomatosis  is  not  evident  in  the  tissues. 

The  usual  adenomatous  enlargement  of  the  pituitary  body  and  the 

frequent  diminution  or  goitrous  condition  of  the  thyroid  have  led  to  the 

belief  that  acromegalia  is  a  trophoneurosis  dependent  upon  modifications 

1  "Eevue  de  Med.."  1886.  ^  "  jour.  Meut.  and  Xerv.  Dis.,"  N.  T.,  1892. 


TROPHONE  UROSES. 


483 


of  the  fu notions  of  these  glands,  especially  of  the  pituitary.  Rogo- 
witsch,  for  example,  considers  that  these  glands  destroy  certain  sub- 
stances which  have  a  toxic  influence  on  the  central  nervous  system. 
Others  think  that  they  secrete  certain  substances  needful  to  the  proper 
action  of  the  trophic  apparatus.  All  that  can  now  be  said  is  that  the 
prehypophysis  cerebri  is  nearly  if  not  always  hypertrophied,  but  whether 
as  a  cause  or  result  is  not  determined.  It  is  true,  however,  that  tumors 
and  other  destructive  conditions  of  the  pituitary  have  been  found  with- 
out acromegalia.  ^  Caselli  contends  that  the  pituitary  gland  is  essential 
to  life  in  dogs  and  cats,  while  Friedman  and  Maas  ^  deny  it.  Israel  ^ 
reports  a  well-marked  case  of  acromegaly  under  observation  for  some 
years  in  which  the  pituitary  gland  was  normal. 

Morbid  Anatomy. — The  bones  of  the  face,  cranium,  extremities, 
and  to  a  lesser  degree  those  of  the  trunk,  show  hypertrophy.  The 
frontal  and  occipital  bones  are  commonly  thickened  and  their  markings 
exaggerated.     The  frontal  and  maxillary  sinuses  are  enlarged  and  the 


Fig.  210. — 1,  Base  of  cranium  showing  excavation  of  the  sella  and,  2,  pituitary  tumor  in  a  case  of 

acromegalia  (Marie). 


pituitary  fossa  is  greatly  increased  in  size.  The  inferior  maxilla,  the 
malars,  the  zygomatic  arches,  and  the  superciliary  ridges  of  the  frontal 
are  particularly  enlarged.  There  is  commonly  elongation  of  the 
spinous  processes  in  the  cervicodorsal  region,  and  the  bodies  of  the 
vertebrae  are  sometimes  increased  in  the  anteroposterior  diameter.  The 
ribs,  clavicles,  and  sternum  are  commonly,  and  the  shoulder-blades 
occasionally,  enlarged.  In  the  limbs  the  hypertrophy  is  most  marked 
toward  the  distal  extremities.  The  long  bones  of  the  leg  and  forearm  are 
most  changed  at  their  lower  ends.  The  metacarpals,  metatarsals,  and 
phalanges  are  particularly  involved.  Histologically,  the  hypertrophy 
is  a  true  one,  bone  being  deposited  under  the  thickened  periosteum  and 
the  central  canal  enlarged  by  the  action  of  osteoblasts. 

The  pituitary  gland  is  enlarged  and  hypertrophic,  filling  up  the  dis- 
tended and  enlarged  sella  turcica  and  commonly  compressing  the  optic 

1  JokolofE,  "  Virchow's  Archiv,"  Bd.  xliii.  ^  "Berlin,  med.  Woch.,"  1900. 

^  "Virchow's  Archiv,"  vol.  clxiv,  344. 


484 


NEUB08ES. 


chiasm  and  adjoining  structures.  It  practically  constitutes  an  endo- 
cranial  tumor.  Striimpell  ^  is  inclined  to  think  it  an  essential  finding. 
In  many  cases  it  has  been  found  to  have  undergone  changes,  probably 
secondary  in  point  of  time  and  nature.  Tamburini  ^  believes  the  first 
stage  is  one  of  enlargement  and  increased  function,  followed  by  adeno- 
matous, sarcomatous,  or  cystic  degeneration.  A  number  of  cases  show- 
ing such  degenerative  changes  are  cited  by  Striimpell  ^  and  reported  by 
others. 

In  the  extremities  and  other  portions  affected  by  the  hypertrophic 
enlargement  the  shin  in  its  epithelial,  dermal,  glandular,  and  muscular 
parts  is  hypertrophically  exaggerated.  The  connective  tissue  particu- 
larly is  increased.  The  subcutaneous  nerve-filaments  are  sometimes  de- 
generated as  a  result  of  the  fibrous  hyperplasia,  but  this  does  not  extend 


Fig.  211.— Skiagraphs  of  hands :  A,  Case  of  acromegalia  ;  B,  normal  hand. 


into  the  nerve-trunks.  The  skin  is  frequently  overactive  and  the  per- 
spiration may  be  excessive  and  disagreeably  fetid.  In  color  the  skin  is 
usually  muddy,  especially  toward  the  extremities,  and  frequently  marked 
with  warts  and  pendulous,  soft  fibromata.  The  cutaneous  sensihility  is 
practically  normal,  but  these  patients  are  usually  very  sensitive  to  gold. 
The  mueous  membrane  of  the  nasopharynx,  larynx,  and  tongue  are  simi- 
larly affected.  The  kidneys  often  show  a  moderate  chronic  parenchy- 
matous nephritis,  with  interstitial  fibrosis.  The  spleen  and  lymphatic 
glands  may  be  sclerosed  ;  the  thyroid  is  usually  atrophic ;  the  thymus 
may  persist  and  even  be  enlarged.  It  is  to  be  noticed  that,  while  paren- 
chymatous glandular  structures  generally  are  atrophic,  the  pituitary  is 
hypertro])hic. 

Symptoms. — Among  the  most  common  symptoms  of  acromegalia 


1  "Deutsche  Zeit.  f.  Nervenheilk.,"  1897. 

2  "  Centralblatt  f .  Nervenli.,"  Dec,  1894. 


^  Loc.  cit. 


TROPHONEUROSES. 


485 


we  may  name  hypertrophy  of  the  face,  hands,  and  feet,  visual  defects, 
dorsal  kyphotic  deformities,  persistent  headache,  sexual  failure  in  men, 
and  amenorrhea  in  women. 

Tlie  face  is  notably  deformed.  The  greatly  enlarged,  overhanging 
brows  are  marked  by  shaggy,  coarse  eyebrows.  Thickened  eyelids  ;  some- 
times exophthalmos  ;  a  heavy,  large,  flabby  nose  ;  great  cheek-bones ;  an 
enormous  mouth,  correspondingly  thickened  lips,  and  a  much  enlarged  and 
prognathic  lower  jaio  are  some  of  the  facial  characteristics.  The  heavy 
features,  puffy  face,  and  accentuated  nasolabial  folds  give  an  expression 
of  grief  and  suffering.  When  the  mouth  is  opened,  it  is  seen  that  the 
hypertrophic  enlargement  o^  the  jaws,  especially  of  the  mandible,  causes 
the  teeth  to  stand  separately  and  at  considerable  intervals.  The  mucous 
membrane  is  also  thickened  and  the  tongue  is  notably  enlarged,  in  some 
instances  reaching  an  enormous  size.     The  soft  palate,  pharynx,  and 


Figs.  212  and  213. — Face  in  acromegalia,  two  cases.    Note  enlarged  superciliary  ridge,  thickened  lips, 
massive  jaw,  and  geueial  grossness. 


larynx  equally  share  in  the  hyperplasia,  and  the  tonsils  and  follicular 
structures  are  also  increased  in  size.  The  ears  and  occiput  are  some- 
times enlarged,  sometimes  not.  The  scalp  is  thickened,  the  hair  coarse, 
thick,  and  harsh.  The  complexion  is  usually  sallow  and  the  parts  are 
elastically  doughy  to  the  touch,  showing  no  pits  on  pressure. 

The  hands  are  greatly  enlarged  in  all  their  dimensions,  but  particu- 
larly in  width.  The  proportion  of  fingers  to  hand  and  hand  to  wrist 
is  retained ;  they  are,  therefore,  enlarged  symmetrically.  The  fingers 
are  thick  and  sausage-shaped,  the  hand  thick  and  beefy,  the  thenar  and 
hypothenar  eminences  greatly  but  proportionately  enlarged.  The  whole 
hand  is  described  as  "  spade-like  or  battledore-shaped."  This  appearance 
is  sometimes  intensified  by  a  comparative  thinness  of  the  forearms.  The 
joints  are  never  limited  in  their  range  of  motion,  and  the  parts  are  sur- 
prisingly supple  and  flexible.      The  palmar  furrows  are  usually  much 


486 


NEUROSES. 


deepened,  the  shin  thick  and  resilient,  the  hairs  coarse,  the  nails  broad- 
ened, thick,  and  strongly  striated  longitudinally. 

The  feet  show  similar  changes,  and  usually  there  is  a  heavy  welt  of 
fibro-elastic  increase  around  the  heel  and  along  the  outer  border  of  the 
foot. 

The  tho7'ax  usually  presents  an  anteroposterior  curvature  in  the  cer- 
vicodorsal  region,  which  may  be  compensated  by  lumbar  lordosis  and 
attended  by  scoliotic  twists.  The  clavicles  are  almost  invariably  increased 
in  thickness  and  sometimes  in  length,  and  the  sternum  may  also  share  in 
the  hypertrophy.  The  ribs  and  cartilages  are  often  enlarged.  These 
bony  changes  give  the  chest  an  unusual  breadth  and  anteroposterior 
depth.  The  respiration  is  ordinarily  abdominal  in  character,  and  the 
abdomen  is  often  protuberant  or  even  pendulous.  The  pelvic  girdle  may 
be  enlarged. 

The  external  genitalia  in  women  are  ordinarily  hypertrophied,  the 
uterus  atrophic.  In  men  there  may  be  hypertrophy  or  atrophy  of  the 
external  genitals.  Amenoyi'hea  and  sterility  are  the  rule  with  women, 
sexual  inappetence  and  impotence  with  men. 

Cephalalgia  of  an  intense,  persistent,  deep-seated  character  is  present 
in  the  great  majority  of  cases. 


Fig.  214. — 1  aud  2,  Hand  in  acromegalia ;   3,  foot  in  acromegalia. 


Speech  is  frequently  thickened  from  the  clumsiness  and  voluminous 
size  of  the  tongue,  and  the  voice  is  ordinarily  very  deep,  strong,  and 
rough,  owing  to  the  enlargement  of  the  larynx,  which  to  palpation  may 
appear  of  increased  dimensions  and  unusual  prominence. 

The  organs  of  special  sense  may  all  be  aifected.  Smell,  taste,  or  hearing 
may  be  reduced  or  abolished,  but  this  is  uncommon.  Vision,  however, 
is  usually  more  or  less  affected  eventually.  This  may  arise  from  optic 
neuritis  or  from  atrophy,  and  in  either  case  points  to  encephalic  tumor. 
Amblyopia,  blindness,  intra-ocular  pains,  exophthalmos,  contraction  of 
the  visual  field,  temporal  hemianopsia,  and  miosis  have  been  noted.    The 


TROPHONEUROSES. 


487 


bilateral  loss  of  the  temporal  fields  or  their  manifest  reduction  indicates 
injury  to  the  chiasm  by  the  pituitary  tumor. 

The  muscular  st/stem  may  be  normal  or  some  atrophy  may  be  found, 
but  g;eneral  muscular  weakness  is  the  rule.  The  reflexes  are  normal  or 
diminished.  The  electrical  responses  are  frequently  quantitatively  re- 
duced. Cardiac  hypertrophy,  arteriosclerosis,  varicose  veins,  and  slight 
lymphatic  adenopathy  may  be  encountered.  The  thyroid  may  be  absent, 
normal,  or  hypertrophic.  Polyuria,  glycosuria,  polydipsia,  excessive 
appetite  for  food,  and  dyspepsia  are  common. 

General  physical  feebleness  is  usual,  and  mental  sluggishness,  irrita- 
bility, and  inaptitude  are  common. 

Course  and  Forms. — The  disease  is  of  insidious  onset  and  slow 
progression,  presenting  a  duration  of  twenty  to  thirty  years  and  ter- 
minating by  a  cachectic  state  marked  by  great 
muscular  weakness,  during  which  death  often 
occurs  suddenly  through  cardiac  failure.  Inter- 
current affections  find  acromegalics  very  vul- 
nerable. 

We  may  distinguish  tivo  varieties  of  acrome- 
galia, depending  mainly  upon  the  age  at  which 
the  disease  commences  and  the  condition  of  epi- 
physeal ossification  with  the  diaphyses :  (1)  Before 
complete  ossification  takes  place  the  enlargement 
is  not  only  in  lateral  dimensions,  but  also  in 
length,  and  the  limbs  become  disproportionate  to 
the  body,  producing  gigantism.  Autopsical  find- 
ings by  Hutchinson,  Dana,  Bramwell,  Taruffi,  and 
skiagraphical  investigations  by  Marinesco  conclu- 
sively show  this  relation.  (2)  After  the  diaphy- 
ses and  the  epiphyses  are  united  by  bone,  only 
circumferential  increase  is  produced,  and  the 
stature,  from  scoliosis,  may  actually  be  reduced. 
The  commoner  massive  type  originally  described  is 
then  developed. 

Diagnosis. — The  diagnosis  can  rarely  present 
difficulty  if  the  disease  has  attained  any  consider- 
able degree  of  development.  Myxedema,  shows  no  ' 
osseous  deformities,  and  the  thickening  of  the  soft  parts  is  waxy  and 
boggy.  Pulmonary  osteo-arthropathy  presents  joint-changes  and  a  chronic 
pulmonary  process.  The  clubbed  enlargement  of  the  fingers  is  largely 
confined  to  the  terminal  phalanges,  over  which  the  hypertrophic  nails 
hang  like  parrot-beaks.  In  hyperostosis  cranii  the  hands,  feet,  and 
mandible  are  not  affected.  Paget's  disease,  or  osteitis  deformans,  spares  the 
face,  but  affects  the  skull,  and  causes  bowing  of  the  long  bones,  especially 
the  femora  and  tibiae.     The  x-ray  may  show  excavation  of  the  sella. 

Prognosis. — The   progress,  as  above  indicated,  is  toward  physical 

helplessness  and  mental  depression,  wliich  in  more  than  one  instance 

have  led  to  suicide.      According  to  Thompson,  ^  the  disease  may  run  an 

acute,  intermittent,  or   chronic  course,  lasting  from  two  to  thirty  years. 

1  "  Brit.  Med.  Jour.,"  April  9,  1899. 


Fig.  215.  —  Cervicodor- 
sal  curvature  of  spine  ;  chest 
and  abdominal  distortion  in 
acromegalia  (Marie). 


488  NEUROSES. 

Sudden    death    from    cardiac    failure  is    rather  frequent.     As  yet  the 
disease  is  not  therapeutically  manageable. 

Treatment  is  confined  to  relieving  the  cephalalgia  and  correcting 
the  symptomatic  disturbances  as  far  as  possible.  For  the  first,  phenacetin 
and  similar  synthetical  anodynes  seem  to  be  most  efficacious.  Treatment 
by  thyroid,  thymus,  and  pituitary  preparations,  singly  or  combined,  seems 
to  be  of  little  avail,  except  in  some  instances  to  reduce  weight,  and  then 
often  at  the  expense  of  the  general  health  and  strength.  Animal  extracts 
may,  however,  yet  control  the  malady,  but  a  recession  of  osteal  hyper- 
trophy is  too  much  to  reasonably  anticipate  when  once  it  has  developed. 

HYPERTROPHIC  OSTEO-ARTHROPATHY. 

In  1890  Marie  and,  independently,  Bamberger  described  cases  of 
chronic  intrathoracic  disease  attended  by  skeletal  deformities.  For 
such,  Marie  proposed  the  term  osteo-arthropathie  hyjiertrophiante  pneu- 
mique.  Massalongo,  Thayer,  and  others  insist  that  the  pulmonary  factor 
is  by  no  means  essential,  and  Thayer  ^  found  it  absent  in  12  out  of  55 
typical  cases.  Other  chronic  conditions  to  which  it  is  secondary  are 
syphilis,  heart  disease,  diarrhea,  and  spinal  caries.  It  has  been  associated 
with  phthisis,  empyema,  bronchiectasis,  pulmonary  syphilis  and  neo- 
plasms, pleurisy,  bronchitis,  and  gastric  dilatation.  The  disease  pre- 
sents a  multiple  osteitis,  affecting  mainly  the  terminal  phalanges  of  the 
hands  and  feet,  the  extremities  of  the  long  bones  of  the  limbs,  and  the 
neighboring  joints.  The  affected  bones  are  enlarged,  rarefied,  and  show 
the  evidence  of  inflammation.  The  cartilages  are  eroded,  the  synovial 
membranes  thickened.  The  bones,  however,  may  escape,  ^  the  enlarge- 
ment of  the  finger-ends  being  due  to  an  excess  of  subcutaneous  fat. 
The  fingers,  owing  to  the  globular  enlargement  of  the  distal  phalanges, 
have  been  likened  to  drumsticks.  The  nails  are  greatly  enlarged  and 
overhang  the  thickened  finger-ends  like  a  parrot's  beak.  Usually  they 
are  thin  and  smooth.  The  joints  creak  and  grate  on  motion,  and  the 
ankles  and  wrists  are  ordinarily  broadened  and  thickened.  Elbows 
and  knees  may  be  similarly  affected,  and  the  toes  show  deformities  and 
disproportions  similar  to  those  of  the  fingers.  The  invariable  presence 
of  chronic  toxemic  states  indicates  a  toxic  basis  for  the  trophoneurosis ; 
for  instance,  Preble  ^  noted  it  in  a  case  of  gastrectasis. 

The  disease  usually  is  of  insidious  onset  and  is  frequently  attended 
by  rheumatoid  pains.      It  may  occur  at  any  age. 

The  diagnosis  is  commonly  easily  made,  though  at  first  this  dys- 
trophic disease  was  confused  with  acromegalia.  It  does  not  affect  the 
head,  face,  or  soft  parts,  and  does  involve  the  joints.  In  acromegalia 
the  fingers  and  toes  are  uniformly  enlarged,  and  the  wrists  and  ankles 
are  not  disproportionately  increased  in  size.  The  facies  of  acromegalia 
is  never  seen  in  pulmonary  osteo-arthropathy. 

The  disease  runs  a  protracted  course,  but  may  come  to  a  standstill, 
or  it  may  recede  slightly  if  the  thoracic  condition  is  greatly  improved. 
Desmons  and  Beraud  *  report  some  improvement  following  subcutaneous 
injections  of  extracts  made  from  sheep's  lungs. 

1  "  Phila.  Med.  Jour.,"  Nov.  5,  1898.  *  "  Medicine,"  Jan.,  1898. 

2E.  F.  Buzzard,  "Br.  Med.  Jour.,"  June  1,  1902.  *  "Archives  gen.de  MM.,"  1894. 


TROPHONEUROSES. 


489 


HYPEROSTOSIS  CRAJMIL 

Virchow  used  the  term  leontiasit^  o-'isea,  Starr,  megalocephaUe,  and 
Putnam,  hyperostosis  cranil  to  designate  certain  rare  cases  in  which  the 
bones  of  the  cranium,  and  less  markedly  those  of  the  face,  undergo 
enormous  enlargement.  The  process  is  apparently  inflammatory  in 
character,  but  its  symmetrical  distribution,  association  with  develop- 
mental periods  of  life,  and  progressive  nature  point  to  a  lack  of  trophic 
control.  Putnam,  1  accepting  seven  from  Baumgarten's  list,  has  been 
able  to  tabulate  fifteen  cases,  including  that  of  Edes.     Morton  Prince  ^ 


Fig.  216. —Hyperostosis  cranii  (Putnam). 

believes  that  this  condition  is  but  a  part  of  osteitis  deformans,  with 
which  it  is  sometimes  associated,  and  that  both  are  of  neuropathic 
origin.  In  the  majority  the  disease  appears  under  thirty  years  of 
age,  and  often  in  childhood  or  at  puberty.  The  cranial  enlargement 
is  sometimes  preceded  by  inflammations  about  the  head,  such  as  erysip- 
elas, and  by  traumatism.  Early  symptoms  have  been  headache,  drow- 
siness, epileptic  attacks,  deafness,  and  blindness.  Mental  irritability  or 
enfeeblement  is  common.  Exophthalmos,  loss  of  hearing,  facial  palsy, 
optic  neuritis,  and  blindness  are  due  to  local  or  intracranial  pressure. 
The  anterior  portion  of  the  head  is  usually  most  enlarged,  and  the  upper 

^  "  Amer.  Jour.  Med.  Sciences,"  July,  1896. 
*  "  Amer.  Jour.  Med.  Sciences,"  Nov.,  1902. 


490  NEUROSES. 

facial  bones  are  more  affected  than  the  inferior  maxilla.  Prognathism 
is  not  commonly  observed.  There  is  usually  a  large  increase  in  the 
bitemporal  diameter.  In  some  instances  the  bones  are  rather  evenly 
enlarged ;  in  others  there  are  numerous  exostotic  thickenings,  both  on 
the  outer  and  inner  surface  of  the  cranium,  or  on  either  aspect  alone. 
The  cervical  vertebrae  are  sometimes  also  enlarged.  The  disease  is 
progressive  and  not  amenable  to  treatment.  Putnam,  Starr,  and  others 
have  tried  thyroids  in  vain.  Encephalic  pressure  may  in  suitable  cases 
be  relieved  by  trephining. 

MYXEDEMA. 

Under  the  generic  term  of  myxedema  it  is  proposed  to  bring 
together  those  clinical  variations  of  nutritive  disorder  dependent  upon 
partial  or  complete  cessation  of  thyroid  activity.  In  1873  Gull  de- 
scribed a  cretinoid  state  occurring  in  adult  ivomen.  Four  years  later  Ord 
reported  additional  cases  and  proposed  the  word  myxedema  (mucous 
swelling).  Charcot,  about  this  time,  struck  by  the  cutaneous  thicken- 
ing and  the  cachectic  state,  used  the  term  pachydermatous  cachexia. 
In  1880  Bourneville  and  d'Olier  described  a  case  of  myxedematous 
idiocy  and  subsequently  many  more.  In  1882  Reverdin,  and  shortly 
afterward  Kocher,  reported  myxedema  following  complete  extirpation 
of  the  thyroid,  for  which  they  severally  proposed  the  terms  of  operative 
myxedema  and  cachexia  strumipriva.  The  analogies  between  acquired 
myxedema,  myxedematous  idiocy,  and  cretinism  have  been  noted  by 
many,  and  Brissaud,  in  his  lectures  of  1893— '94,  brings  certain  cases  of 
infantilism,  or  physical  retardation,  into  the  same  category.  We  will 
commence  by  a  description  of  acquired  myxedema  in  adults.  Due 
allowance  being  made  for  the  age  and  growth  of  the  individual,  and  the 
suddenness  and  completeness  with  which  the  thyroid  is  affected,  will 
practically  enable  this  description  to  be  applied  to  all  the  above- 
mentioned  varieties. 

Acquired  myxedema  of  adults  is  of  insidious  onset,  as  a  rule, 
and  more  common  in  women  than  in  men.  It  usually  appears  between 
the  ages  of  thirty  and  fifty.  Occasionally  it  has  abrujDtly  followed  an 
attack  of  acute  rheumatism,  some  infectious  fever,  or  a  severe  hemor- 
rhage. It  is  marked  by  :  (1)  Tumefaction  of  the  dermal  and  mucous 
structures  ;  (2)  by  intellectual  and  physical  enfeeblement,  and  (3)  by 
atrophy  of  the  thyroid  body. 

The  dermal  changes  are  the  most  striking.  The  skin  is  infiltrated 
with  a  mucoid  substance  and  the  fatty  panniculus  is  frequently  greatly 
thickened.  The  swelling  offers  an  elastic  resistance  to  the  touch  and 
does  not  pit  on  pressure.  The  color  is  usually  pale,  yellowish,  and  waxy 
or  cheesy.  The  face  is  enlarged,  rounded,  and  apathetic.  The  heavy, 
thickened  lids  droop  over  the  eyes,  the  nose  and  lips  are  thickened, 
the  brow  is  furrowed,  the  ears  enlarged,  and  the  cheeks  rounded  and 
showing  jelly-like  trembling  on  slight  jarring.  The  whole  appear- 
ance is  one  of  hebetude  and  stupidity.  The  skin  of,  the  trunk  and 
extremities  is  likewise  infiltrated.  In  tlie  axillae  and  subclavicular 
depressions  lipomatous-like  masses  are  often  encountered.     The  hands 


TROPHONEUROSES. 


491 


and  feet  are  enlarged  with  cushion-like  swellings  on  their  dorsal  surfaces ; 
the  digits  are  thick  and  clumsy.  The  scrotum  is  often  much  thick- 
ened. The  epidermal  structures  are  greatly  aifected.  The  skin  is  dry, 
harsh,  and  branny.  The  hair  becomes  dry  and  scanty  on  all  portions 
of  the  head  and  body.  The  nails  are  dry,  fragile,  striated,  atrophic. 
Perspiration  and  sebaceous  secretions  are  defective.  The  mucous  mem- 
branes, wherever  visible,  are  tumefied,  pale,  dry,  and  elastic.  Mucous 
polypi  in  the  nasopharynx  are  not  uncommon.  The  tongue  is  thickened 
and,  with  the  infiltrated  condition  of  the  buccal,  pharyngeal,  and  laryn- 
geal mucous  membranes,  explains  the  muffled  voice  and  difficulty  of 
swallowing. 


Fig.  217.- 


-A  case  of  myxedema  before  and  after  two  months'  treatment  by  thyroids 
(Dr.  John  Woodman). 


The  intellectual  state  in  myxedema  is  uniformly  marked  by  apathetic 
enfeeblement,  and  cerebral  torpor  shows  itself  in  sluggish  mentation, 
defective  memory,  slow  speech,  and  lethargic  movements.  Myxedemic 
patients  are  usually  indolent  both  mentally  and  physically,  and  are 
irritable  and  somnolent.  Some  cases  show  nocturnal  insomnia  and  are 
troubled  by  disturbing  dreams.  The  sluggishness  of  movement  and 
the  clumsiness  of  the  hands  and  feet  are  due  to  the  cerebral  torpor  and 
the  local  thickenings.  These  patients  have  no  muscular  energy  and  are 
promptly  fatigued  on  the  slightest  continuous  effort,  but  there  is  no 
palsy. 

The  thyroid  in  the  great  majority  of  cases  can  not  be  detected  by 
palpation.     There  may  be  a  history  of  its   former  presence  or  actual 


492  NEUROSES. 

enlargement,  and  even  a  goitrous  condition  may  persist.  In  some  in- 
stances exophthalmic  goiter  has  preceded  myxedema  and  they  have  also 
been  found  associated,  but  Graves'  disease  does  not  follow  myxedema. 

Less  prominent  and  constant  conditions  in  myxedema  are  :  cardiac 
weakness,  irregular  pulse,  hemorrhages  (especially  metrorrhagia),  a  sub- 
normal temperature,  loss  of  teeth,  habitual  constipation,  and  occasionally 
albuminuria  in  advanced  cases.  The  patients  complain  of  headaches, 
vertigo,  throbbing  in  the  ears,  and  particularly  and  almost  constantly  of 
a  sensation  of  cold.  Sensations  objectively,  motor  conditions,  and  the 
reflexes  are  normal. 

Usually  insidious  in  onset,  the  disease  runs  a  slow,  tardy,  progressive 
course.  Remissions  of  longer  or  shorter  duration  may  occur,  as  in 
summer,  or  by  removal  to  a  warm  climate,  and  pregnancy  sometimes 
has  a  similar  retarding  effect.  The  general  tendency  is  toward 
cachectic  helplessness  and  death  by  marasmus.  In  the  very  last  stages 
the  tumefaction  may  disappear.  Pulmonarj^  complications,  especially 
tuberculosis,  are  common,  and  cardiac  asthenia  may  strike  the  final 
note.  Fortunately,  treatment  is  now  equal  to  the  requirements  of  these 
otherwise  hopeless  cases. 

Operative  myxedema  is  usually  the  result  of  the  total  extirpation 
of  the  thyroid,  which  it  follows  in  from  three  to  six  months.  Removal 
of  a  part  of  the  thyroid,  the  remainder  being  completely  disabled, — by 
cystic  disease,  for  instance, — results  in  myxedema.  This  is  initiated  by 
lassitude,  physical  enfeeblement,  sensations  of  cold,  heaviness  in  the 
limbs,  sluggish  and  clumsy  movements.  Shortly  the  integument  tume- 
fies and  becomes  discolored,  the  hair  falls,  and  cutaneous  functions  lag. 
The  cerebral  torpor  follows  and  myxedema  is  fully  established.  Tetany 
may  also  develop,  due,  according  to  Murray,  ^  to  the  loss  of  the  parathy- 
roid bodies,  which  in  man  are  included  in  the  lobes  of  the  thyroid.  The 
course  is  usually  progressive,  but  is  more  subject  to  remissions  than  in 
the  spontaneous  variety.  Other  cases  improve,  owing  to  the  compen- 
satory action  of  unremoved  portions  of  the  gland,  or  to  the  development 
of  accessory  thyroids,  or  through  the  vicarious  activity  of  other  gland- 
ular structures.  The  gravity  of  operative  myxedema  is  great  in  pro- 
portion as  the  patient  is  young.  Occurring  in  childhood,  or  at  any  period 
before  adult  life,  it  retards  or  completely  checks  growth,  and  produces 
a  persistent  infantilism  or  a  myxedematous  idiocy.  It  is,  however, 
completely  amenable  to  the  thyroid  treatment. 

Congenital  myxedema,  myxedematous  idiocy,  or  sporadic 
cretinism  is  usually  first  noticed  at  about  one  year  of  age,  or  upon 
weaning,  and  thereafter  presents  all  the  characteristics  of  adult  myx- 
edema, excepting  that  the  mental  faculties  never  develop  and  physical 
growth  is  retarded  to  the  last  degree.  It  is  frequently  congenital,  and 
Horsley  has  found  it  in  a  dead-born  fetus.  It  is  encountered  in  the 
offspring  of  degenerate,  alcoholic,  or  phthisical  parents.  At  twenty  years 
of  age  these  cretinoid  idiots  may  be  of  little  more  than  two  feet  of 
stature.  The  relatively  normal  size  of  the  head  contrasts  with  the 
dwarfish  body.  The  skull  is  full  behind,  contracted  and  narrow  in 
1  "Br.  Med.  Jour.,"  Mar.  18,  1899. 


TROPHONEUROSES. 


493 


front,  often  with  persistent  fontanel.  The  flabby,  thickened  features ; 
snubbed  nose,  thick  lips,  drooping  eyelids,  mouth  agap,  lolling,  hyper- 
trophic tongue,  and  drooling  saliva  make  up  a  peculiarly  repulsive 
appearance.  Add,  now,  the  short,  often  lipomatous,  neck  ;  a  protuberant 
abdomen,  often  showing  inguinal  and  umbilical  ruptures  ;  a  deviating 
spine,  rudimentary  genitals,  and  dwarfish,  crooked  limbs,  and  it  is  im- 
possible to  imagine  a  less  human-looking  object  with  human  attributes. 
Sparse  hair,  eczema,  and  an  infiltrated,  inactive  skin  are  commonly 
present.  The  thyroid  is  absent.  Idiots  mentally,  they  can  ordinarily 
exercise  a  little  attention  and  even  show  some  aifection.  In  some  in- 
stances they  assist  themselves  in  eating  and  dressing.  They  never 
learn  to  speak,  and  never  show  signs  of  pubescence.  Often  even  the 
first  dentition  is  extremely  defective.  On  the  other  hand,  they  lack 
the  destructiveness,  noisiness,  tics,  convulsions,  onanism,  balancing  and 
motor  disturbances  so  common  in  idiocy  from  cerebral  lesion.     These 


Fig.  218. — Sporadic  cretin  before  and  after  twelve  months'  thyroid  treatment :  1,  Five  years  old  ;  2,  one 

year  later  (Parker) . 


unfortunate  creatures  may  attain  thirty  or  forty  years  of  age,  and 
usually  die  of  pulmonary  concomitants. 

The  disease  is  also  amenable  in  some  degree  to  the  thyroid  treat- 
ment. 

Cretinism  is  a  term  of  ancient  lineage  and  honored  usage,  but  of 
somewhat  uncertain  definition.  It  has  been  applied  to  the  goitrous  and 
feeble-minded  natives  of  localities  where  goiter  is  endemic.  Certain 
valleys  in  France,  Spain,  Italy,  and  Switzerland,  and  some  parts 
of  Great  Britain,  Sweden,  and  of  other  countries  widely  scattered 
over  the  globe  present  endemic  conditions  that  predispose  to  goit- 
rous enlargements.  Such  an  endemic  has  been  noted  in  Minnesota 
and   Ontario.     A   few   definite   facts   are    the    results   of   observations 


494 


NEUROSES. 


extending  over  generations  in  some  of  these  communities.  The  oif- 
spring  of  two  goitrous  parents,  according  to  Kocher,  is  invariably  a 
cretin,  who  may  or  may  not  be  goitrous,  but  is  myxedematous.  A 
non-goitrous  cretin  invariably  has  goitrous  antecedents  and  is  indistin- 
guishable from  the  myxedematous  idiot  or  sporadic  cretin,  the  condition 
also  being  congenital.  In  the  goitrous  cretins  the  thyroid  disease  may 
appear  at  any  period  of  life,  and  acts  then,  exactly  as  does  spontaneous 
myxedema  or  operative  myxedema,  to  stunt  growth  and  stop  mental 
development.  The  goitrous  cretin  is  usually  also  myxedematous  and 
may  present  any  degree  of  mental  impairment,  from  mere  simple- 
mindedness  to  abject  brutishness.  The  distribution  of  endemic  cretinism 
is  identical  with  that  of  endemic  goitrous  disease,  and  Kocher  believes 
this  to  be  due  to  organic  infections  through  the  water-supplies. 

The  only  distinction  between  endemic  cretins  and  other  myxedemic 

patients  is  the  goitrous  enlarge- 
ment. This  may  be  only  a  differ- 
ence of  degree,  because  the  cystic 
degeneration  and  interstitial  hy- 
pertrophy at  the  bottom  of  the 
goitrous  enlargement  of  the  thy- 
roid is  destructive  in  character 
and  effect.  It  is  easily  conceiv- 
able that  myxedema  and  mental 
disturbances  will  be  developed 
proportionately  to  the  lack  of 
functionally  active  thyroid.  When 
the  thyroid  is  entirely  wanting,  as 
in  the  non-goitrous  congenital 
cretin,  or  completely  destroyed  in 
some  goitrous  cretins,  the  myx- 
edema is  correspondingly  intense 
and  the  mental  degeneration  pro- 
portionately developed.  It  would 
seem,  therefore,  that  the  causes  at 
the  bottom  of  endemic  cretinism 
are  those  that  produce  endemic 
goitrous  disease,  to  which  the  cre- 
tinoid state  is  secondary.  These 
are  not  well  understood,  but  usu- 
ally the  soil,  drinking-water,  and  atmospheric  conditions  are  held  ac- 
countable. 

Infantilism  and  Myxedematous  Retardation. — Occupying  a 
middle  ground  between  myxedematous  idiocy  and  acquired  myxedema 
there  are  numerous  cases  showing  slight  cutaneous  tumefaction,  retarded 
mental  development,  and  diminished  growth.  These  patients  retain 
their  childishness  both  in  mental  attributes  and  physical  conformation. 
Perhaps  here  belong  some  of  the  idiots  classed  as  Mongolian  by  the 
English,  and  some  of  the  infants  ariearre  of  the  French.  In  at  least 
one  well-marked  instance  Brissaud   found  the   thyroid  body    scarcely 


Fig.  219. — Myxedematous  cretin  eighteen  years  old 
(Parker). 


TROPHONEUROSES. 


495 


perceptible.  At  the  age  of  ten  numerous  and  large  cervical  glands 
had  been  removed  with  probable  resulting  damage  to  the  thyroid. 
Thereafter  the  physical,  genital,  and  mental  growth  of  the  lad  had 
remained  stationary.  Schmidt  ^  has  treated  three  cases  of  this  sort  in 
which  growth  was  retarded,  by  the  administration  of  thyroids,  with 
immediate  improvement. 

Etiology. — If  we  look  upon  myxedema  as  the  manifestation  of 
defective  thyroidation,  its  causes  are  those  of  disease  or  absence  of  the 
thyroid  body.  In  some  cases  it  is  a  teratological  defect ;  in  others  it  is 
the  result  of  a  thyroiditiH  which  may  be  dej)endent  on  infectious  processes, 
as  the  infectious  fevers,  rheumatism,  etc.;  in 
others  it  is  cystic  degeneration;  in  others  the 
result  of  trauma  or  surgical  extirpation.  Taking 
all  causes  of  myxedema  together,  there  is  a  pre- 
ponderance of  females  which  reaches  large  propor- 
tions in  the  spontaneous  adult  varieties.  It  is 
probable  that  the  close  relation  of  the  thyroid 
and  uterine  functions  is  at  the  bottom  of  this 
fact.  It  is  only  necessary  to  mention  the  in- 
creased size  of  the  thyroid  in  pregnancy,  its  fre- 
quent enlargement  in  pubescent  girls,  its  usual 
congestion  in  some  women  during  menstruation, 
and  its  final  retraction  at  the  menopause.  Ery- 
sipelas of  the  neck  and  head  and  syphilis  of  the 
thyroid  gland  have  induced  myxedema. 

Regarding  the  manner  in  which  defective 
thyroidation  affects  the  trophic  apparatus  and 
induces  the  mucoid  deposits,  two  general  points 
of  view  depending  upon  opposite  physiological 
hypotheses  are  maintained.  As  yet  all  is  theory. 
Many,  with  Schiif,  believe  that  the  normal  thy- 
roid elaborates  some  substance  indispensable  to 
the  proper  action  of  the  nervous  system.  This 
substance,  however,  has  never  been  isolated  nor 
its  characteristics  determined.  Others,  with  Hors- 
ley,  conceive  that  the  thyroid  transforms  the  mu- 
cinoid  elements  of  the  blood  into  utilizable  meta- 
bolic constituents,  or,  as  a  modification  of  this 
idea,  that  the  thyroid  eliminates  certain  harmful 
elements  from  the  blood.  The  blood  in  myxedema 
is  poor  in  oxygen  and  the  urine  is  of  an  increased 
toxicity.  Both  of  these  conditions  are  favorably 
modified,  as  is  the  myxedematous   state,  by  the 

administration  of  thyroids.  It  now  is  determined  that  the  thyroid 
gland  is  essential  to  life  and  to  the  proper  neurotrophic  balance.  That 
it  is  essentially  secretory  is  proven  by  its  embryonal  duct  in  man  o])en- 
ing  at  the  root  of  the  tongue  and  its  active  connection  with  alimentary 
processes  in  the  lower  orders. 

1  "  Therapeutische  Wochen.,"  Nov.,  1896. 


Fig.  220. — Myxedema- 
tous infantilism,  youth  nine- 
teen years  old  (Brissaud). 


496  ^^'EUIiOSES. 

Morbid  Anatomy. — The  primal  lesion  of  myxedema  is  located  in 
the  thyroid.  In  myxedematous  idiocy  the  gland  is  either  wanting,  rudi- 
mentary, or  atrophic.  In  acquired  myxedema  it  is  atrophic,  yellowish 
white,  and  fibrous.  At  first  there  appears  to  be  an  embryonal  vesicular 
infiltration,  with  epithelial  proliferation.  Later,  fibrous  changes  pre- 
dominate, and  finally  complete  sclerosis  is  presented.  This  practically 
constitutes  a  parenchymatous  and  interstitial  thyroiditis.  Murray,  how- 
ever, believes  that  atrophy  of  glandular  tissue  is  the  first  step,  due 
probably  to  the  action  of  some  toxic  agent,  and  that  the  increase  of 
fibrous  tissue  is  a  replacement-fibrosis.  The  cystic  degeneration  of 
cretinoid  goiter  reaches  the  same  results  by  its  destructive  action  upon 
the  glandular  parenchyma. 

The  subcutaneous  cellular  tissues  are  infiltrated  with  a  gelatinous, 
mucinoid  substance  and  the  fatty  panniculus  is  much  increased.  Through- 
out the  organism  there  is  a  tendency  to  fibrous  proliferation  which 
especially  aifects  glandular  organs,  as  those  of  the  skin  and  the  kidneys. 
3Iucin  has  also  been  found  in  the  blood  and  in  all  the  tissues  of  the 
body.  The  pituitary  gland  and  the  thymus  are  frequently  enlarged, 
apparently  for  the  purpose  of  compensation.  The  nervous  system  pre- 
sents no  changes  that  are  uniform  or  significant.  Central  hyperemia 
and  tumefaction  of  the  nerve-cells  have  been  noted  by  Rogowitch. 

Treatment. — The  treatment  of  myxedema  furnishes  one  of  the 
most  brilliant  chapters  in  medicine.  It  was  observed  that  in  animals 
and  man  myxedema  did  not  follow  partial  ablation  of  the  thyroid,  and 
SchilF  found  that  a  portion  of  the  gland  subcutaneously  or  intraperitoneally 
implanted  prevented  the  myxedematous  state  in  animals  subsequently  thy- 
roidectomized.  Horsley  suggested  the  same  procedure  in  man,  and  it 
was  carried  into  eifect  by  Kocher,  Lannelongue,  Bircher,  and  others  with 
favorable  results.  When  the  thyroid  graft  was  successful,  myxedema 
was  temporarily  checked.  Murray  first  used  subcutaneous  injections  of 
thyroid  extracts  or  emulsions  with  better  and  more  persistent  results,  and 
a  series  of  cures  were  reported  by  this  method  in  the  hands  of  numerous 
observers.  Howitz,  of  Copenhagen,  followed  shortly  and  independently 
by  Mackenzie  and  Fox  in  England,  and  then  by  a  host  of  physicians  the 
world  over,  fed  myxedemic  patients  with  thyroids  raw,  partially  cooked, 
or  desiccated.  The  results  were  almost  uniformly  good.  The  pro- 
cedure is  perfectly  justified  not  only  by  clinical  results,  but  by  the  fact 
that  in  lower  animals  and  in  the  human  embryo  the  thyroid  gland  fur- 
nishes a  secretion  to  the  alimentary  canal  by  a  duct  opening  at  the  fora- 
men cecum  on  the  base  of  the  tongue.  The  sheep's  tliyroid  is  habitually 
employed  and  is  now  an  article  of  commerce  in  the  form  of  various 
powders  and  tablets.  The  equivalent  of  one-half  a  sheep's  thyroid  may 
be  administered  daily,  and  if  well  tolerated,  increased  to  a  full  thyroid  or 
more.  If  prompt  action  is  secured,  it  may  be  reduced,  and  if  difficulties 
arise,  it  must  be  discontinued  and  resumed  with  caution.  The  exhibition 
of  thyroids  is  followed  in  a  day  or  two  by  a  return  of  the  temperature  to 
the  normal  standard,  which  it  may  even  exceed  by  a  degree  or  two;  the 
pulse  becomes  more  rapid,  the  urine  increases  in  volume,  the  pigmentary 
infiltration  diminishes,   the  fatty  deposits  melt  away,   and  the  patient 


TROPHONEUROSES.  497 

becomes  more  animated  and  cheerful.  Four  to  eight  weeks  may  show 
a  marvelous  change.  The  skin  becomes  softened  and  moist,  the  hair 
and  nails  are  better  nourished,  and  the  normal  state  of  the'  patient  is 
shortly  attained.  To  maintain  the  cure,  thyroid  feeding  must  be  main- 
tained. If  the  treatment  is  discontinued,  the  patient  promptly  relapses. 
The  equivalent  of  one  thyroid  a  week  is  usually  sufficient  for  the  pur- 
pose, and  cases  are  now  on  record  in  which  several  years  have  been 
passed  in  apparent  health  and  vigor  under  this  regime. 

The  treatment  is  attended  by  considerable  danger,  and  in  some  in- 
stances it  has  been  followed  by  fatal  results.  Headaches,  pains  in  the 
bowels,  diarrhea,  neuralgia,  insomnia,  malaise,  and  nervous  excitement 
are  some  of  the  unpleasant  symptoms  which  should  promptly  lead  to  a 
reduction  of  the  dose  or  to  the  temporary  interruption  of  the  treatment. 
When  the  terminal  cachexia  of  myxedema  has  appeared,  this  treatment 
is  hazardous,  but  nothing  else  can  possibly  rescue  the  patient,  and  in 
some  such  cases  it  has  done  so.  In  children,  especially  in  myxedema- 
tous idiots  with  rachitic  deformities,  thyroids  tend  to  produce  a  soften- 
ing of  the  bones  that  may  greatly  exaggerate  the  osseous  distortions. 
Parker  1  and  others  have  met  with  this  complication,  and  have  recom- 
mended that  such  cases  be  treated  in  bed,  and  the  weight  kept  oif  the  legs. 

In  acquired  or  operative  myxedema  thyroid  feeding  may  be  consid- 
ered established  as  a  curative  treatment.  In  cases  of  myxedematous 
retardation  its  results  appear  equally  brilliant.  In  sporadic  cretinism  it 
is  capable  of  producing  the  most  marvelous  improvement,  which  is  com- 
plete in  proportion  as  it  is  adopted  early  in  life.  In  endemic  cretinism 
its  effects  are  beneficial,  but  as  yet  its  proper  value  is  not  established. 

The  action  of  thyroidin,  a  chemical  compound  isolated  by  Baumann,  ^ 
is  practically  the  same  as  that  of  the  various  preparations  of  the  gland, 
but  is  less  likely  to  be  attended  by  the  accidents  of  ptomain  poisoning. 
Against  the  tetany  that  sometimes  follows  removal  of  the  thyroid,  it  is 
less  efficient  than  the  thyroids  themselves. 


EXOPHTHALMIC  GOITER. 

Exophthalmic  goiter,  otherwise  known  as  Graves'  disease,  Base- 
doiv's  disease,  cardiotkyroid  exophthahnos,  and  struma  exophthahnica, 
presents,  in  most  respects,  a  complete  contrast  to  myxedema,  but  also 
shows  some  analogous  features.  We  have  considered  myxedema  as 
due  to  defective  thyroidation,  and  we  may,  at  least  tentatively,  look 
upon  Graves'  disease  as  the  manifestation  of  excessive  or  perverted  thy- 
roid activity,  or  of  both.  The  disease  is  manifest  by  the  three  so-called 
■cardinal  symptoms  of  rapid  heart,  enlarged  thyroid,  and  prominent  eye- 
balls. To  this  must  be  added  a  fine  tremor,  mental  irritability,  and 
muscular  weakness,  which  are  equally  common.  Further,  nearly  ever}^ 
function  of  organic  life  may  be  disturbed.  Flajani,  in  Italy,  described 
the  condition  in  1802^  and  Parry,  in  England,  in  1825.  Graves  taught 
it  as  a  disease  entity  in  1835,  and  published  it  as  such  in  1843  ;  mean- 
while Basedow,  in  Germany,  had  independently  written  of  it  in  1840. 

^  "  Brit.  Med.  Jour.,"  July,  1896.         ^  ^otkin,  "  Wien.  klin.  Woch.."  Oct.  22,  1896. 
32 


498  KEUBOSES. 

This  serves  to  explain  the  various  names  applied  to  it  in  diiferent 
countries. 

Etiology. — Graves'  disease  belongs  to  the  reproductive  period  of 
life,  being  exceedingly  rare  before  pubert}^  and  after  the  menopause,  and 
affects  females  five  or  six  times  as  frequently  as  males.  A  neuropathic 
heredity  is  commonly  encountered.  Pubescence  in  girls,  menstrual  diffi- 
culties, chlorosis,  and  all  debilitating  conditions  act  as  predisposants. 
In  exceptional  instances  Graves'  disease  seems  to  be  due  to  certain 
intranasal  and  intra-abdominal  conditions.  As  exciting  causes  may  be 
mentioned  emotional  and  mental  shocks,  especially  profound  and  pro- 
tracted anxiety  and  grief,  but  frequently  cases  attributed  to  such  causes 
can  be  traced  back  of  them.  In  such  instances  the  mental  strain  may 
serve  to  precipitate  the  more  prominent  symptoms  of  the  disease. 
Pregnancy  may  seem  to  excite  the  disease.  Occurring  during  its  course, 
the  disease  is  sometimes  apparently  modified  for  the  better,  but,  on  the 
other  hand,  may  be  aggravated.  After  delivery  there  is  frequently 
distinct  improvement.  Graves'  disease  is  often  associated  with  other 
neuroses,  such  as  chorea,  hysteria,  and  epilepsy.  It  is  observed  sometimes 
with  tabes,  and  the  mental  disturbance  not  infrequently  reaches  into 
the  field  of  insanity.  A  family  type  ^  is  sometimes  encountered,  aifect- 
ing  several  or  all  ofPspring  of  parents  who  may  show  no  abnormality. 
A  special  but  rare  association  of  Graves'  disease  is  with  tetany,  scler- 
oderma, myxedema,  and  acromegaly.  All  of  which  are  closely  allied 
through  relation  to  the  thp'oid  body. 

Numerous  theories  as  to  its  pathogenesis  have  been  entertained. 
Graves  considered  it  a  disease  of  the  heart.  Marshall,  Taylor,  and  Piorry 
attributed  it  to  mechanical  compression  of  the  cervical  vessels  and  nerves. 
After  the  experiments  of  Claude  Bernard  upon  the  cervical  sympathetic, 
lesions  of  this  portion  of  the  nervous  apparatus  were  believed  to  be  at 
the  bottom  of  exophthalmic  goiter.  Following  Charcot,  the  disease  was 
by  many  considered  a  pure  neurosis  similar  to  hysteria.  At  present  there 
are  two  general  theories  in  the  field.  One  incriminates  the  medulla, 
the  other,  the  thyroid.  Pointing  to  the  bulbar  origin  of  the  disease  is 
the  association  of  cardiac,  vasomotor,  secretory,  and  thermic  disturb- 
ances, to  which,  in  various  rare  cases,  palsies  of  cranial  nerves,  pro- 
ducing ophthalmoplegia,  facial  palsy,  trigeminal  neuralgia,  and  auditory 
disturbance  are  added.  In  certain  cases  bulbar  hemorrhage,  atrophy  of 
the  restiform  bodies,  and  degeneration  of  the  solitary  bundles  have  been 
found,  and  the  association  with  tabes  argues  the  same  cause.  Felehne  and 
Dardufi,  by  experimental  lesions  of  the  restiform  bodies,  have  produced 
the  major  symptoms  of  exophthalmic  goiter.  As  a  rule,  however,  the 
btilb  is  not  structurally  affected,  and  the  diverse  conditions  cited  are  as 
likely  to  be  effect  as  cause. 

Following  Johnston  there  are  many  who  believe  that  overactivity  of 
the  thyroid  gland,  causing  a  hyperthyroidation,  explains  the  genesis  of 
exophthalmic  goiter.  The  principal  facts  supporting  this  point  of  view 
are  :  (1)  The  usual  changes  and  enlargement  of  the  thvroid  ;  (2)  the  im- 
provement and  cures  resulting  upon  removal  of  a  portion  of  the  gland  ;. 
(3)  the  symptoms  of  exophthalmic  goiter  induced  by  overdoses  of  thy- 
1  Brower,  "Chicago  Med.  Rec,"  1898  ;  Holmes,  "  Phila.  Med.  Jour.,"  June  11,  1898. 


TBOPHONE  UBOSES.  499 

roids  in  myxedematous  patients  and  normal  individuals ;  (4)  the  cases  in 
which  exophthalmic  goiter  has  eventuated  in  myxedema  through  de- 
generative changes  in  the  gland,  and  (5)  the  almost  absolute  contrast 
between  myxedema  and  Graves'  disease. 

Horsley,  who  has  given  most  constant  and  careful  attention  to  this 
subject  for  many  years,  and  to  whose  investigation  we  owe  much  of  our 
present  knowledge  regarding  the  functions  of  the  thyroid  body,  insists 
upon  the  changes  in  the  gland  and  its  secretion.  He  declares  that  "  ex- 
ophthalmic goiter  in  its  various  degrees  results  from  perversion  of  the 
function  of  the  thyroid  gland."  ^  It  has  been  found  by  many  observers 
that  the  use  of  thyroids  in  Graves'  disease  often  intensifies  all  the  symp- 
toms, but  there  are  certain  cases  in  which  they  seem  to  cause  improve- 
ment. Is  it  not  reasonable  to  suppose  that  when  the  gland  is  simply  or 
mainly  overacting  their  administration  increases  the  hyperthyroidation, 
but  may  benefit  the  cases  that  by  perversion  of  thyroid  function  are  not 
supplied  with  a  normal  secretion?  Cunningham, ^  on  experimental 
grounds,  readies  with  Gley  the  conclusion  that  the  majority  of  symptoms 
in  Graves'  disease  may  be  plausibly  explained  by  the  hypothesis  of 
deficient  thyroid  activity.  The  question  of  the  relation  of  thyroid  action 
to  the  functions  of  the  nervous  system  has  been  already  outlined  in  the 
description  of  myxedema  (see  p.  495). 

Accepting  the  thyroid  theory,  we  are  still  confronted  with  the  initial 
question  as  to  why  the  thyroid  function  is  primarily  disturbed.  Some 
have  attributed  this  to  infection  setting  up  a  thyroiditis,  and  point  to 
the  frequent  history  of  antecedent  infectious  fevers,  etc.  Others  accuse 
the  neuropathic  heredity  or  constitution.  The  real  cause  still  escapes 
us.  The  intimate  relation  of  thyroid  and  uterine  functions  (see  p.  495) 
and  the  usual  occurrence  of  exophthalmic  goiter  during  reproductive 
life  are  of  interest. 

Morbid  Anatomy. — The  autopsical  findings  in  exophthalmic  goiter 
are  inconstant  and  variable.  The  heart  is  often  dilated  ;  the  sometimes 
thickened  walls  may  present  fatty  degeneration.  The  valves  are  dis- 
eased only  as  accidental  concomitants.  The  thyroid  body  may  present 
any  goitrous  variation  from  simple  congestion  to  the  most  destructive 
lesions.  Usually  the  lobes  are  unequally  enlarged,  firm  to  the  touch, 
and  present  a  reddish,  pulpy  aspect.  Colloid  degeneration  in  places  is 
not  uncommon  and  may  result  in  cystic  formation.  The  vessels  are 
thickened,  dilated,  and,  in  chronic  cases,  atheromatous.  There  is  a  pro- 
liferation of  connective  tissue  throughout  the  gland  which  may  reach  a 
sclerotic  degree.  The  acini  of  the  gland  become  dilated  ;  the  colloid 
material  disappears,  leaving  a  granular  debris  ;  the  secretion  becomes 
thin  and  watery,  the  epithelium  more  or  less  disintegrated.  The  thymus 
is  often  persistent  and  enlarged,  showing  increased  vascularity  and 
an  attempt  at  compensatory  or  perhaps  at  antagonistic  activity.  The 
orbital  cavity  is  often  normal,  but  as  frequently  presents  some  fatty  pro- 
liferation, and  almost  always  the  evidence  of  a  continuous  retrobulbar 
congestion. 

On  the  part  of  the  nervous  system  the  alterations  in  the  cervical  sym- 

1  "British  Med.  Jour.,"  Dec  5,  1896.         ^  "  jour.  of  Experimental  Med.,"  1898. 


500  NEUROSES. 

pathetic  ganglia,  described  in  early  accounts,  are  not  found.  Changes 
attributable  only  to  the  cachectic  state  are  detected.  In  the  bulb  and 
spinal  cord  vascular  degeneration  has  been  encountered,  with  occasional 
small  hemorrhages  and  dilatations.  Atrophy  of  the  restiform  bodies 
and  of  the  solitary  bundles  has  been  noted  once  or  twice,  as  has  atrophy 
of  the  ascending  root  of  the  trifacial.  The  associated  lesions  of  tabes 
are  more  frequent. 

The  muscles,  according  to  Askanzy,i  show  fatty  infiltration,  usually 
distinct  to  the  naked  eye.  The  fat  globules  are  seen  microscopically  in 
long  rows  in  the  muscle-fibers,  which  also  show  increased,  sometimes 
degenerated  nuclei. 

Symptoms. — The  onset  of  exophthalmic  goiter  is  frequently  in- 
sidious, and  the  patient  can  scarcely  say  when  it  began.  In  other  in- 
stances the  major  symptoms  appear  within  a  few  days  or  even  within 
a  few  hours,  following  some  inciting  shock,  but  it  is  always  allowable 
to  suppose  that  unobserved  minor  manifestations  had  been  previously 
present.  Such  fact  can  frequently  be  elicited  by  judicious  inquiry. 
Cardiac  palpitation,  nervousness,  irritability,  and  unaccountable  fatigue 
are  often  felt  for  months  before  the  more  prominent  symptoms  are 
declared. 

Cardiovascular  Features. — The  cardiac  disturbance  usually  is  the 
first  of  the  triad  of  cardinal  symptoms  to  appear.  The  pulse  becomes 
rapid,  and  ordinarily  reaches  120  a  minute,  unless  the  patient  is 
reclining  and  at  perfect  rest,  when  it  may  drop  to  90,  but  never  reaches 
normal  during  the  activity  of  the  disease.  A  rate  of  150  or  even  200 
is  not  very  rare.  Of  the  three  major  symptoms  a  rapid  pulse  may 
alone  exist,  and,  taken  with  several  other  and  minor  symptoms,  may 
suffice  for  a  diagnosis.  It  is  the  only  essential  symptom.  Ordinarily 
regular,  the  rhythm  of  the  heart-beat  in  some  cases  is  greatly  disturbed. 
The  heart  acts  in  the  most  tumultuous,  irregular  manner,  and  its  in- 
competence is  shown  by  vertigo,  cyanosis,  and  precordial  distress.  Pal- 
pitation and  cardiac  throbbing  are  experienced  by  most  patients,  and 
may  be  occasioned  by  the  slightest  physical  or  mental  distress.  At  such 
times  the  breast,  neck,  and  face  are  frequently  suiFused,  and  hot  waves, 
with  violent  blushes,  may  sweep  over  the  upper  part  of  the  chest,  neck, 
and  face.  At  first,  and  sometimes  throughout  the  disease,  the  stetho- 
scope reveals  nothing  but  the  tachycardia  and  violent  systole.  Func- 
tional systolic  bruits  and  anemic  murmurs  are  not  infrequent.  Organic 
valvular  disease  is  practically  an  accidental  complication.  An  apparent 
hypertrophy  is  really  due  to  dilatation  and  to  the  enlarged  area  over 
which  the  apex-beat  extends  by  its  increased  violence.  In  late  cachectic 
stages  the  dilatation,  with  degeneration  in  the  heart-muscle,  becomes 
physically  apparent  and  threateningly  promment. 

The  entire  circulatory  system  is  affected.  This  is  most  manifest  in 
the  aortic  branches,  especially  in  the  cervical  arteries,  and  is  seen  in  the 
temporal  and  the  retinal  arteries  and  veins.  It  is  less  well  marked  in  the 
extremities,  but  Gerhardt  ^  has  noted  it  in  the  palmar  arches  and  in  the 

1  "  Deutsch.  Arch.  f.  klin.  Med.,"  Band  61. 

2  "  Centralblatt  f .  Chirurgie,"  Sept.  5,  1896. 


TROPHONEUROSES.  501 

crurals.  He  also  calls  attention  to  the  presence  of  capillary  pulsation 
in  the  spleen  and  liver  and  kidneys.  In  cases  of  long  standing,  vascular 
dilatation  is  produced  and  the  veins  themselves  become  fibrous  and 
arterialized. 

The  g-oiter  may  appear  at  any  period  of  the  disease  or  may  never 
develop.  In  some  instances  it  is  of  insidious  growth,  and  the  patient's 
attention  is  only  incidentally  called  to  it  by  tightness  of  the  ordinary 
neckwear.  In  other  instances  it  is  of  sudden  development,  or  may  ad- 
vance in  size  at  intervals,  or  advance  and  recede  repeatedly.  In  any 
case  it  rarely  attains  very  large  proportions,  and  practically  never  inter- 
feres mechanically  with  respiration.  It  is  usually  asymmetrical,  the  right 
lobe  commonly  being  most  affected.  The  swelling  may  be  confined  to 
one  lobe,  usually  the  right,  or  it  may  involve  the  isthmus  alone.  The 
tumor  usually  offers  considerable  resistance  to  palpation,  and  a  pulsatile 
thrill  is  frequently  to  be  detected.  In  some  instances  nodules,  indic- 
ative of  parenchymatous  changes,  can  be  made  out.  Auscultation  over 
the  enlarged  thyroid  readily  detects  in  most  cases  a 
bruit  synchronous  with  the  pulse,  and  the  tumor  can 
often  be  seen  to  expand  with  every  systolic  impulse. 
By  manual  compression  it  may  often  be  greatly  re- 
duced in  size  for  the  moment,  and  it  has  a  tendency 
to  fluctuate  in  volume  during  the  progress  of  the  dis- 
ease, increasing  in  size  upon  the  occasion  of  any 
physical  or  mental  excitement.  In  late  cases,  through 
interstitial  thickening  or  cystic  degeneration,  it  may 
give  a  sclerous  or  fluctuant  feeling  to  the  touch,  and 
does  not  then  recede  upon  the  cessation  of  the  malady. 
It  may  even  become  markedly  atrophic,  and  then 
myxedema  gradually  develops.  Fig.  221 -Fades  in 

Ocular   Conditions. — With  the  appearance    of  Graves'  disease. 

exophthalmos,  which  usually  promptly  follows  the 
goitrous  enlargement,  the  famous  triad  of  symptoms  is  complete.  It 
may  appear  before  the  goiter  or  in  cases  that  never  show  thyroid  enlarge- 
ment. Both  eyes  commonly  are  affected,  but  at  first  usually  in  unequal 
degree,  and  exceptionally  but  one  is  prominent.  This  occurs  usually  in 
cases  in  which  only  one  lobe  of  the  thyroid  is  enlarged,  and  commonly 
on  the  same  side.  ^  The  prominent  eyeballs  with  wide-open  lids  give 
an  expression  of  excited  fierceness  and  fright  strangely  mingled,  and 
quite  disconcerting  to  strangers.  The  ocular  protrusion  varies  greatly 
in  amount  in  different  patients,  but  in  extreme  cases  has  caused  actual 
dislocation  of  the  eyeball.  Unless  it  exceed  a  moderate  amount  it  occa- 
sions no  inconvenience  and  may  even  escape  the  patient's  attention.  In 
a  more  pronounced  degree  the  exophthalmos  induces  some  difficulty  in 
ocular  movements  and  causes  ocular  fatigue.  When  exophthalmos  is 
well  marked,  a  distinct  bruit  has  been  heard  by  placing  a  stethoscope  on 
the  closed  lids.^  The  cornea  may  also  become  inflamed  from  inade- 
quate protection,  es})ecially  at  night  and  in  the  wind.  There  is  fre- 
quently an  increased  lacrimation,  which  may  occur  independently  of 

iPridenberg,  "Med.  Record,"  July  13,  1895. 
2  Sanger  Browu,  personal  communication. 


502  NEUBOSES. 

the  exophthalmos,  and  later  the  secretion  of  tears  may  be  defective. 
Conjunctivitis  and  keratitis  may  arise  as  complications,  and  i^erforation 
by  ulceration  has  been  kno^yn. 

The  lids  are  usually  retracted  and  often  show  peculiar  and  important 
motor  difficulties.  Winking  is  infrequent,  but  in  occasional  instances  is 
rapidly  repeated  at  momentary-  intervals.  Von  Graefe  noted  that  in 
looking  down  the  upper  lid  did  not  correspondingly  follow  the  move- 
ment of  the  ball  as  in  health.  This  sign  is  not  related  to  the  amount  of 
exophthalmos,  as  it  is  sometimes  found  in  normal  individuals,  and  may 
be  absent  in  marked  cases  of  Graves'  disease.  Stellwag  called  atten- 
tion to  the  usual  widening  of  the  palpebral  fissure  and  the  incomplete 
closure  of  the  lids  even  when  the  patient  thinks  the  eyes  are  firmly 
closed.  In  a  few  cases  Joffroy  has  noted  a  similar  inactivity  of  the 
lower  lid  and  of  the  frontalis  in  looking  upward,  voluntary  control 
of  the  latter  muscle  remaining  perfect.  The  outline  of  the  palpebral 
fissure  is  often  more  or  less  angular,  losing  its  smooth  curves.  Mobius 
has  called  attention  to  a  difficulty  of  convergence  that  is  commonly 
present.  In  exceptional  cases  an  external  ophthalmoplegia  has  been 
seen.     Paresis  of  the  frontalis  or  of  the  entire  facial  nerve  or  involve- 


Figs.  222  and  223.— Exophlhaliuic  goiier.  1,  SLowo  exoijUihalmus  aud  the  thyroid  tumor  ;  2,  the 
peculiar  outline  of  the  palpebral  opening  and  the  failure  of  the  brows  and  lower  lifls  to  ascend  ia 
looking  ujjward. 

ment  of  the  sensoiy  and  motor  portions  of  the  trifacial  has  been  noted. 

Vision  is  usually  intact  and  the  pupils  are  normal,  but  myopia  may 
develop  on  extreme  pressure  from  exophthalmos.  The  eye-grounds 
show  no  abnormality  aside  from  retinal  congestion  and  dilated,  some- 
times pulsating,  vessels.  Photophobia  and  brilliant  muscse  are  attribu- 
table to  the  retinal  congestion,  and  hallucinations  of  sight  may  have  the 
same  origin. 

Motor  Conditions. — Besides  the  motor  disturbances  of  the  eye  and 
its  appendages,  previously  indicated,  the  entire  musculature  is  aifected 
with  such  marked  weakness  that  Charcot  was  led  to  describe  a  Base- 
dowian  paraplegia.  Muscular  asthenia  is  often  an  early  symptom.  The 
reflexes  may  be  diminished  and  the  legs  may  suddenly  give  way,  causing 
the  patients  to  fall  heavily.  Of  similar  origin  are  the  shallow  respiratory 
excursions  and  diminished  expansion  of  the  chest.  Cramps,  contractures. 


TROPHONEUROSES.  503 

fleeting  tetanoid  conditions,  and  even  epileptiform  crises  have  been 
noted.  The  occasional  association  of  chorea,  epilepsy,  and  hysteria  has 
already  been  mentioned,  and  must  not  be  confounded  with  motor  dis- 
turbances due  to  Graves'  disease. 

An  almost  constant  symptom  in  Graves'  disease  is  2i  fine  tremor  which 
is  as  significant  as  any  one  of  the  cardinal  triad.  It  is  of  variable 
intensity,  may  appear  only  at  intervals,  and  be  limited  to  the  head  and 
upper  extremities.  By  placing  the  finger-tips  on  the  head  when  the 
patient  is  sitting  or  standing,  the  examiner  will  be  aware  of  a  vibration, 
and  this  may  be  demonstrated  by  placing  a  long  feather  in  the  patient's 
hat.  It  usually  is  easily  seen  in  the  extended  hands,  especially  if  the 
fingers  be  spread  widely,  or  it  may  be  then  felt  by  grasping  the  patient's 
wrist.  In  some  cases  the  entire  trunk  is  affected,  and  in  standing,  the 
tremor  may  be  present  in  the  lower  extremities.  It  is  sometimes  dis- 
tressing to  the  patient,  but  often  occasions  no  complaint,  and  must  be 
intelligently  sought.  The  rapidity  of  the  tremor  is  from  eight  to  ten 
oscillations  a  second. 

Secretory  and  Vasomotor  Features. — With  the  hot  waves  and 
morbid  blushing  that  have  already  been  noted  there  is  often  profuse 
perspiration,  which  may  be  widely  distributed,  limited  to  one  side  of  the 
body,  or  most  abundant  on  the  hands  and  feet.  In  some  cases  it  necessi- 
tates frequent  changes  of  underclothing.  Usually  it  is  attended  by  a 
feeling  of  almost  unbearable  heat,  and  these  patients  often  seek  cool 
rooms  even  in  winter  and  find  all  bed-covering  intolerable.  The  bodily 
temperature  may  be  quite  normal,  but  in  rare  instances  an  elevation  of 
from  one  to  five  degrees  has  been  noted,  and  in  the  terminal  cachexia  of 
fatal  cases  hyperpyrexia  is  commonly  encountered.  Hemorrhages  from 
the  uterus,  nose,  gums,  and  lips  are  not  infrequent.  ^  Polyuria,  especially 
periodical  polyuria,  is  a  common  phenomenon,  and  glycosuria  is  sometimes 
encountered.  Albuminuria,  however,  is  the  rule  at  some  period  of  the 
disease.  It  is  usually  intermittent  and  appears  when  the  other  manifes- 
tations of  the  disease  are  exaggerated,  as  if  due  to  the  hypervascularity 
of  the  medulla.  Edema  is  common,  but  peculiar  and  usually  circum- 
scribed ;  it  may  affect  the  upper  eyelids  and  has  a  preference  for  the 
outer  aspect  of  the  legs,  the  thighs,  and  the  abdomen.  The  infiltration 
is  not  boggy  and  does  not  pit  on  pressure,  but  reminds  one  of  the  resi- 
liency of  myxedematous  swelling.  In  rare  instances  it  may  become 
generalized  and  does  so  in  those  cases  that  eventually  develop  myx- 
edema. 

Mental  Disturbances. — From  the  beginning,  and  often  for  a  long 
period  antecedent  to  the  appearance  of  cardiac  symptoms,  the  subjects 
of  Graves'  disease  present  a  considerable  mental  erethism.  There  is 
an  indefinable  and  tormenting  agitation,  marked  by  mental  and  motor 
restlessness  and  an  imperative  and  impulsive  tendency  to  be  doing. 
Their  emotions  are  too  readily  excited,  and  they  are  unusually  impres- 
sionable and  irritable,  reacting  in  an  exaggerated  manner  to  all  the  inci- 
dents of  daily  life.  In  more  pronounced  cases  they  become  voluble 
and  manifest  the  greatest  mobility  of  ideas,  without  persistent  concen- 
tration or  logical  order.  Their  affections  are  likely  to  undergo  modifi- 
1  S.  PopofE,  ''Neurol.  Centralbl.,"  April,  1900. 


604  NEUROSES. 

cations,  and  they  become  irascible,  fault-finding,  inconsiderate,  ungrate- 
ful, and  hard  to  live  with.  In  some  instances  this  disturbance  of 
mentation  carries  them  over  the  border  into  active  mania,  marked, 
perchance,  by  delusions  of  fear,  due  to  the  cardiac  symptoms  or  the 
sensations  of  heat.  Insomnia  is  often  added,  and  the  fitful  sleep  is 
disturbed  by  horrifying  dreams  that  are  likely  to  be  projected  into  the 
waking  moments  and  woven  into  delusions  which  are  usually  unsys- 
tematized, and  constantly  changing,  furnishing  the  analogue  of  the  motor 
restlessness.     Hallucinations  of  sight  and  hearing  are  not  uncommon. 

The  mental  perturbation  only  rarely  reaches  the  degree  of  actual 
mania,  and  then  is,  perhaps,  equally  dependent  upon  numerous  other 
causes  acting  in  a  neurotic  individual.  But  a  condition  of  abnormal 
mental  stimulation  is  characteristic  of  the  malady,  and  as  important  an 
index  as  any  of  the  cardinal  triad. 

The  skin  is  often  marked  by  abnormal  pigmentation,  which  may  be 
distributed  in  irregular  plaques  over  the  body,  face,  and  limbs,  or  in 
rare  instances  produces  zebra-like  markings  on  the  trunk.  In  certain 
cases  it  much  resembles  the  bronzing  of  Addison's  disease,  but  usually 
sjiares  the  mucous  surfaces,  though  not  always.  Vitiligo,  scleroderma, 
and  various  cutaneous  eruptions  are  sometimes  encountered,  and  the 
hair  may  become  thin.  The  sensation  of  heat  is  usually  associated  with 
a  diminished  resistance  to  electricity,  which  may  be  reduced  to  a  third  or 
a  fifth  of  the  normal.  This  is  possibly  related  to  the  excessive  perspira- 
tion, but  does  not  obtain  in  other  diseases  in  which  sweating  is  equally 
great. 

Dig-estive  disturbances  are  numerous  and  not  marked  by  anatomical 
lesions.  Anorexia,  voracious  appetite,  vomiting,  diarrhea,  dysentery, 
and  icterus  may  be  encountered  in  different  patients,  or  many  of  them 
at  various  times  in  the  same  patient.  The  diarrheas  are  particularly 
important,  as  they  rapidly  reduce  the  patient's  strength  and  tend  to 
hasten  the  appearance  of  cachexia  and  a  fatal  termination  by  exhaus- 
tion. The  frequent  painless  stools  are  made  up  of  undigested  food 
and  an  abundance  of  watery  mucus,  sometimes  liberally  streaked 
with  blood.  The  defects  in  nutrition  are  always  pronounced  and  a 
loss  of  weight  from  the  first  is  the  almost  exceptionless  rule.  It 
may  occur  intermittently,  the  patient  losing  eight  or  ten  pounds  in 
a  week  and  gradually  regaining  it.  Huchard  ^  is  inclined  to  look 
upon  such  loss  of  weight,  and  especially  upon  its  intermittent  occur- 
rence, as  of  diagnostic  importance.  It  may  occur  independently  of  the 
diarrhea,  sweating,  polyuria,  or  any  other  physical  drain,  and  in  the  face 
of  an  active  bulimia. 

Respiratory  disturbances  are  not  uncommon.  They  are  frequently 
secondary  to  the  cardiac  disorder.  Dyspnea,  asthmatic  attacks,  pul- 
monary congestions,  bronchitis,  and  a  persistent  cough,  without  stetho- 
scopic  symptoms,  may  be  presented.  The  dyspnea  is  the  same  as 
that  in  myxedema,  and  appears  to  be  due  to  the  athyroidal  condition 
(Horsley).  Shallowness  of  respiration  and  inefficient  thoracic  expan- 
sion are  related  and  proportionate  to  the  muscular  asthenia. 

The  genital  functions  are  usually  modified.  Increased  sexual  appe- 
1  "Jour,  de  Med.,"  Feb.  10,  1896. 


TROPHONEUROSES.  505 

tite  has  been  noted  in  men  and  women  in  the  early  periods  of  the 
disease.  Later,  as  general  asthenia  develops,  it  is  correspondingly  re- 
duced. Amenorrhea  is  present,  or  the  tendency  is  well  marked,  and 
leukorrheas  are  abundant. 

The  following  table  of  symptoms  and  their  relative  frequency  is 
based  on  Paessler's  statistics,^  comprising  fifty-eight  cases,  of  which 
forty-two  were  women.  It  must  be  borne  in  mind  that  nearly  all  the 
symptoms  of  Graves'  disease  are  intermittent,  and  any  tabulation,  to  be 
satisfactory,  should  cover  the  entire  course  of  the  disease  and  embrace 
a  very  large  number  of  cases  : 

Table  showing  Relative  Frequency  of  Symptoms  in  Graves'   Disease, 
Based  on  Fifty-eight  Observations. 

Neuropathic  family  history 29      Sensations  of  warmth 24 

Tachycardia    . 57      Vertigo 23 

Nervous  imtability  and  restlessness  .  57      Insomnia 21 

Characteristic  tremor 52      Stellwag's  symptom 20 

Palpitation     and     vascular    disturb-  Tachycardia,    goiter,    exophthalmos, 

ances 50  and  tremor  combined 18 

Goiter 48      Polydipsia • 17 

Increased  perspiration 34      Cardiac  dilatation 15 

Anemia 34      Irritable  cough 10 

Severe  headaches 32      Graefe's  symptom 9 

Exophthalmos 28      Mobius'  symptom 9 

Severe  diarrhea 26      Valvular  heart  disease  = 5 

Course  and  Progress. — The  great  diversity  encountered  among  cases 
of  Graves'  disease  makes  it  diflficnlt  to  outline  its  clinical  course.     It 


Fig.  224.— Partial  recovery.     Some  exophthalmos,  pigmeutation  of  skin,  and  goitrous  thickening  remain. 

may  be  of  apparently  sudden  or  of  insidious  onset,  and  may  show  any 
combination  of  the  long  list  of  symptoms  that  have  been  detailed  above. 
It  may  run  its  course  to  a  favorable  termination  in  three  months  or  may 
take  six  years,  or  continue  throughout  or  terminate  life.  The  great  major- 
ity of  cases  are  of  protracted  duration.  Early  recoveries  and  fatalities  are 
alike  exceptional,  and  when  all  other  symptoms  have  subsided,  prorai- 
1  "Deut.  Zeit.  f.  Nervenheilk.,"  Bd.  vi,  S.  21. 


506  NEUROSES. 

nent  eyes  and  a  moderate  g'oiter  may  remain  to  mark  the  passage  of  the 
disease.  The  appearance  of  active  diarrhea,  of  polyuria,  intense  albumin- 
uria, and  rapid  wasting  darkens  the  prognosis.  Extreme  asystole,  great 
cardiac  dilatation,  and  a  failing  circulation  have  the  same  import. 
Maniacal  disturbance  is  not  of  itself  of  bad  prognosis,  which  depends 
rather  on  failing  bodily  conditions.  The  cardiac  symptoms  are  usually 
the  first  to  appear,  and  aiford  the  best  criterion  as  to  the  progress  of  the 
disease.  Their  improvement  is  the  only  unqualified  sign  of  gain.  A 
state  of  nervous  susceptibility  is  usually  left  after  recover}-  that  may  be 
compromised  by  the  slightest  shock. 

Diagnosis. — In  the  presence  of  the  Basedowian  triad  diagnosis  can 
not  fail,  but  in  the  abortive  forms  it  requires  a  careful  and  thorough 
investigation  and  an  experienced  judgment  to  recognize  the  disease. 
Tachycardia,  wdth  irritability,  sweats,  insomnia,  emaciation,  and  perhaps 
a  slight  rise  in  temperature  may  mimic  'phthisis  Y&ry  closely,  and  if  an 
irritable  cough  is  added,  the  mask  is  almost  impenetrable,  especially  as 
some  pulmonary  dullness,  due  to  the  congestive  condition,  may  be 
present.  The  mental  attitude  is  of  some  assistance,  and  should  the 
tremor  be  observed  or  some  slight  thyroid  turgescence  be  made  out,  the 
diagnosis  may  be  effected.  Some  of  these  formes  frustes  are  put  down 
as  neurasthenia,  in  view  of  the  asthenic  condition  so  commonly  present. 
It  requires  the  presence  of  eye,  thyroid,  cardiac,  or  tremor  symptoms 
to  make  the  diagnosis  positive.  Every  case  of  Graves'  disease  is  at  the 
same  time  myasthenic,  and  may  also  be  neurasthenic. 

Treatment. — In  the  management  of  this  disease,  whatever  line  of 
treatment  may  be  added,  it  is  of  the  utmost  importance  to  secure  rest  and 
qidef.  With  complete  rest^  as  by  the  Weir  Mitchell  course,  some  cases 
make  immediate  and  substantial  progress.  If  this  is  not  available,  it 
should  be  approached  as  nearly  as  the  circumstances  of  the  patient 
permit.  In  the  asthenic,  irritable  state,  a  conservation  of  energy  is 
strongly  indicated.  Dlr/italis,  strophanthus,  and  strychnin  have  a  favor- 
able action  on  the  heart  in  some  cases,  and  strychnin  in  full  doses  is 
occasionally  of  benefit  to  the  general  nervous  condition.  Sedatives  such 
as  hromids  and  helladonna  have  not  yielded  the  writer  good  results  in 
any  instance,  but  chloral  is  often  valuable  for  the  insomnia.  Iron  must 
be  used  with  caution  even  to  combat  the  anemia  so  commonly  present, 
as  it  frequently  disturbs  the  intestinal  tract  and  augments  the  vascular 
storms.  Hydrotherapy  and  massage  are  of  benefit  in  some  cases.  Elec- 
tricity locally  has  strong  advocates,  some  favoring  faradism,  others  gal- 
vanism. A  moderate  faradic  current  through  the  root  of  the  neck, 
causing  all  the  anterior  cervical  muscles  to  contract  about  the  thyroid, 
mechanically  diminishes  it  in  size.  This  may  last  for  a  few  minutes  or 
for  a  few  hours  after  the  current  is  stopped  if  the  patient  is  not  excited 
in  any  way.  An  uninterrupted  galvanic  current  may  produce  a  similar 
result,  and  passed  through  the  temples  occasionally  causes  a  recession 
of  the  eyeballs,  but  the  effect  is  very  fleeting  and  does  not  influence  the 
tachycardia.  Electricity  should  be  used  daily,  or  several  times  a  day. 
Mechanical  compression  of  the  thyroid  by  bandaging  is  insupportable. 

Injections  of  cicatrizing  agents,  such  as  tincture  of  iodin,  into  the 
substance  of  the  gland,  at  one  time  much  in  vogue,  are  now  generallv 


TROPHONEUROSES.  507 

abandoned,  as  they  are  of  doubtful  value  and  are  attended  by  consider- 
able danger  to  life.  In  long-standing  cases  ablation  of  a  portion  of 
the  gland  has  produced  good  results  in  the  hands  of  various  operators, 
but  it  has  a  considerable  mortality — about  twelve  per  cent.  Schulz^ 
reports  fourteen  cases  with  twelve  cures,  but  Sanger  ^  cites  a  case  in 
wliicli  all  symptoms  were  aggravated.  Cystic  portions  may  be  removed, 
but  caution  must  be  exercised  to  leave  a  fair  amount  of  normal  gland. 
The  same  effect  is  obtained  by  exposing  the  gland  by  a  median  incision 
and  securing  it  in  the  wound  (the  exothyropexy  of  Jaboulay),  but  even 
this  comparatively  simple  operation  has  been  followed  by  death.  Thus 
operated,  the  thyroid  shrinks  in  size  and  the  symptoms  decrease.  The 
wound  is  closed  at  a  subsequent  period.  Jonnesco^  and  others  have 
had  improvement  from  bilateral  ablation  of  the  cervical  sympathetic. 
The  operation  is  a  serious  one  and  not  without  bad  results.^ 

Thyroids  have  been  used.  Ordinarily,  they  intensify  the  symp- 
toms. In  a  minority  of  instances  the  goiter  is  reduced  in  size 
quite  promptly,  but  the  pulse  is  usually  not  imj^roved,  and  the 
nerv^ousness  and  tremor  are  generally  accentuated.  They  may  be  care- 
fully tried  experimentally.  A  number  of  cases  have  been  benefited  by 
the  use  of  thymus  feeding.  Owen  ^  has  collected  about  twenty  cases 
in  which  its  effect  was  mainly  beneficial.  Mackenzie,^  in  an  equal  num- 
ber of  cases,  found  it  of  little  or  no  value.  Owen  called  attention  to 
the  probable  physiological  antagonism  between  thymus  and  thyroid 
action.  The  persistence  or  reappearance  of  the  thymus  in  these  cases, 
often  noted,  among  others  by  Hektoen,'^  may  have  the  same  significance. 

The  numerous  complications  must  be  met  as  they  arise.  Atropin  for 
the  sweats,  bismuth  and  opium  for  the  diarrhea,  careful  dieting  for  the 
gastric  and  intestinal  troubles,  and  a  general  tonic  and  upbuilding 
regime.     Thompson,  of  New  York,  insists  on  a  milk  diet. 


SCLERODERMA. 

Scleroderma  is  a  trophoneurosis  presenting  an  induration  and  atrophy 
of  the  skin,  or  atrophy  without  preceding  induration.  It  occurs  (1)  in 
a  generalized  form,  but  affecting  the  extremities  and  face  principally, 
and  (2)  in  a  circumscribed  form,  marked  by  isolated  plaques  and  stripes. 
These  may  be  confined  to  one  side  or  be  roughly  symmetrical  in  distri- 
bution, and  are  often  limited  to  the  cutaneous  extent  of  certain  nerve- 
trunks  or  branches.  This  has  led  Jonathan  Hutchinson  ^  to  use  the 
term  herpetiform  morphea.  The  disease  is  also  known  as  the  hide- 
bound disease,  scleroma  adultorum,  sclerosis,  chorionitis,  morphea,  and 
Addison's  keloid.  When  the  fingers  are  affected,  the  French  employ 
the  term  sclerodactylie.  It  is  a  rare  disease,  but  not  so  uncommon  as 
most  writers  insist,  and  if  generally  recognized  would  soon  present  a 
generous  material. 

1  "  Berliner  Klinik,"  June,  1897.  ^  "  Munch,  med.  Wochens./'  April  6,  1897. 

3  "  Centralbl.  f.  Chir.,"  Jan.  16,  1897.     *  Aschard,  "  Rev.  de  Neurol.,"  Aug.,  1900. 
5  "  British  Med.  Jour.,"  Oct.  10,  1896.  «  "American  Journal,"  Feb.,  1897. 

7  "International  Med.  Mag.,"  Sept.,  1895.         »  "Brit.  Med.  Jour.,"  June  1,  1895. 


508 


NEUROSES. 


Etiology. — The  female  sex  furnishes  about  three-fourths  of  all 
eases.  Generalized  scleroderma  is  most  common  in  adults,  but  may  be 
encountered  between  ten  and  twenty  years  of  age,  and  the  discrete  form 
begins  perhaps  more  commonly  before  twenty-five  than  later  in  life.  It 
has  been  attributed  to  various  infectious  fevers,  to  traumatism,  exposure 
to  cold,  rheumatism,  and  to  pretty  much  every  incident  of  human  life. 
A  neuropathic  constitution  is  of  such  striking  frequency  in  these  cases 

that  it  can  not  be  overlooked.  Spinal  cord 
and  cerebral  lesions  are  sometimes  associated, 
and  in  the  generalized  form  Raynaud's  dis- 
ease is  a  frequent  concomitant.  Insanity  is 
sometimes  present,  especially  melancholia. 

Symptoms. — In  the  generalized  form  of 
scleroderma  at  first  there  is  usually  some 
pain  and  sensitiveness  in  the  part  affected. 
This  is  followed  by  an  induration  and  thick- 
ening that  may  be  red  and  suffused  by  vas- 
cular stasis  and  present  blebs  and  bullae. 
Factitious  urticaria  and  dermographia  are 
commonly  easily  demonstrated.^  On  the 
broad  surfaces  of  the  trunk  the  skin  feels 
stiffened  and  brawny.  It  is  found  to  be 
bound  down  to  the  underlying  parts,  giving 
rise  to  the  hide-bound  descriptive  title. 
Atrophy  occurs  later.  All  the  dermal  struc- 
tures become  thinned  and  present  a  cicatricial 
appearance,  and  may  be  glistening  white. 
The  hands  and  face  are  especially  affected. 
The  fingers  are  reduced  to  their  slightest 
proportions,  and  the  bones,  covered  by  tha 
atrophic,  glistening  skin,  which  fixes  the 
joints  and  limits  motion,  are  lessened  in  size. 
Raynaud's  disorder  is  often  present.  Over 
the  facial  bones  the  parchment-like  integu- 
ments are  tightly  drawn  in  a  motionless, 
unwrinkled  mask.  The  thinned  lids  can 
scarcely  be  closed  over  the  sunken  eyeballs, 
w:hich  consequently  appear  unduly  large.  The  nose  is  thin  and  looks 
ready  to  split  its  way  through  the  skin.  The  lips  are  papery  and  often 
retracted,  exposing  the  teeth.  The  shortening  of  the  skin  from  the  Jaw 
to  the  clavicles  may  even  interfere  with  movement  and  with  deglutition. 
Every  bony  prominence,  as  about  the  orbits,  cheeks,  and  chin,  is  sharply 
defined.  The  epithelial  structures  are  everywhere  reduced,  and  nails 
and  hairs  are  of  defective  growth.  Sensibility  is  not  much  disturbed, 
as  a  rule,  but  hypersensitiveness  may  be  encountered. 

In  the  discrete  form  a   local  thickening  may  gradually  invade  the 

surrounding  parts,  but  is   limited  by  rather  sharp  borders  and  may  be 

attended  by  herpetic  eruptions.      Later  it  becomes  atrophic.      In  other 

cases  a  white  atrophic   spot  appears  and  gradually  extends  over   the 

^  Launois,  "  Nouv.  Icon,  de  la  Salpet.,"  1900. 


derma,  shouing  lacies,  sclerodacty 
lie  and  hide-bound  state  (Grasset). 


TROPHONEUROSES.  509 

course  of  the  supplying  nerve.  It  may  thus  produce  zoster-like 
bands  on  the  trunk  and  stripes  down  the  limbs.  The  most  common 
locations  are  the  face,  chest,  and  lower  extremities.  The  outlines  of 
these  morpheic  tracts  and  plaques  sometimes  forcibly  remind  one  of  the 
cutaneous  areas  of  the  spinal  segments. 

Up  to  the  time  atrophic  changes  occur,  the  disease  may  recede  and 
the  normal  condition  be  spontaneously  established.  Several  years  are 
usually  consumed  in  the  development  of  the  disease. 

Anatomically,  the  disease  is  marked  by  a  fibrosis  attended  or  preceded 
by  vascular  changes.  The  nerves  and  all  structures  within  the  atrophic 
area  equally  show  the  fibrous  proliferation. 

Treatment. — Tonics,  electricity,  hydrotherapy,  massage,  and  gen- 
eral reconstructive  measures  have  been  found  of  some  benefit  in  a  few 
cases.  Of  late,  Lustgarten,  Sachs,  Bramwell,  and  others  have  reported 
great  benefit  from  thyroid  feeding,  which,  even  in  advanced  cases,  caused 
immediate  and  gratifying  changes  for  the  better.  In  recent  cases  it 
appears  likely  to  produce  a  cure.  Whether  a  relapse  will  follow  dis- 
continuance of  the  remedy  is  not  now  certain. 


RAYNAUD'S  DISEASE. 

Raynaud,  in  1862,  described  a  peculiar  dry  gangrene,  especially  in 
the  extremities,  which  he  attributed  to  a  disturbance  of  the  vasomotor 
apparatus.  From  present  information  the  condition  may  better  be 
considered  as  a  generalized  one,  but  with  local  exaggeration.  Naturally, 
the  circulatory  disturbance  is  most  apparent  in  the  extremities,  as  in  the 
fingers,  toes,  nose,  and  ears.  The  arterioles  and  venules  are  spastically 
contracted  during  the  attack.  Raynaud  described  three  stages,  which  he 
strikingly  named  local  syncope,  local  asphyxia,  and  local  death.  The 
condition  is  usually  symmetrical,  may  recede  at  any  stage  short  of 
gangrene,  and  usually  appears  many  times  in  succession  in  mild  degree 
before  inducing  mummification. 

Etiology. — Females  furnish  twice  as  many  cases  as  males  and  no 
age  is  exempt,  though  most  cases  occur  between  twenty  and  forty-five. 
All  varieties  of  anemia  are  strongly  predisposing  factors,  and  a  neuro- 
pathic makeup  is  almost  invariably  present.  Other  nervous  diseases 
are  commonly  associated,  such  as  hysteria,  epilepsy,  tabes,  neurasthenia, 
myelitis,  and  insanity,  especially  acute  mania.  Urticaria,  telangiectasis, 
angioneurotic  edema,  and  scleroderma  may  be  combined  in  the  history 
or  present  in  the  patient.  Urticaria  and  local  asphyxia  may  alternate 
in  the  same  patient.  Heredity  is  apparent  in  ten  per  cent,  of  the  cases 
showing  the  same  disorder  in  blood  relatives.  Any  occupation  attended 
by  exposure  to  cold  and  wet  may  play  a  part  in  the  causation.  Any 
sudden  demand  upon  the  physical  strength  or  powers  of  resistance  may 
induce  the  attack.  Exposure  to  cold  is  the  most  common  immediate 
cause,  but  fright,  grief,  fatigue,  trauma,  influenza,  malaria,  and  acute 
infections  may  induce  it.  Some  consider  the  ultimate  cause  of  the 
angiospasm  to  be  an  auto-intoxication.  It  is  often  associated  with 
scleroderma. 


510  NEUROSES. 

Symptoms. — The  local  symptoms  first  attract  attention.  The 
fingers  and  toes,  less  frequently  the  ears,  nose,  and  lips,  or  a  single 
finger,  appear  pale,  waxy,  bloodless,  and  glossy.  There  is  usually  a 
feeling  of  tingling,  numbness,  and  loss  of  sensibility,  as  in  a  finger 
compressed  by  an  elastic  bandage.  A  needle-prick  draws  no  blood  and 
the  finger  looks  dead  ;  hence  the  term  digiti  mortui.  After  lasting  a  few 
minutes  to  several  hours,  this  condition,  often  attended  by  chilliness, 
nausea,  and  general  discomfort,  may  pass  off  or  develop  the  second  stage 
of  local  asphyxia.  The  affected  part  becomes  cyanotic,  blue-black,  and 
the  anemic  pressure-trace  disappears  very  slowly.  Less  commonly  the 
fingers  in  this  stage  may  puff  up,  present  a  vivid  red  color,  be  extremely 
hot,  and  covered  with  perspiration.  There  is  now  usually  more  or  less 
neuralgic  pain  proportional  to  the  cyanosis.  Both  hands  may  be  simul- 
taneously affected  or  one  may  precede  the  other.  One  finger  may,  in  the 
second  stage,  present  the  extreme  blue-cold  cyanosis,  its  neighbor  the 
turgid,  hot  condition  or  the  white,  syncopic  stage.  If  the  second  stage 
persists  long  enough,  several  hours  at  least,  small  blebs  appear,  raising 
the  epidermis  especially  from  the  pads  at  the  finger-tips,  ulceration  fol- 
lows, and  dry  gangrene  may  mummify  and  destroy  the  terminal 
phalanges  or  entire  fingers.  Small  necrotic  patches  may  form,  and, 
healing  slowly,  leave  cicatrices  to  mark  the  attack.  The  amount  of 
mutilation,  fortunately,  is  often  insignificant  in  relation  to  the  extent  of 
cyanotic  tissue.  A  hand  or  foot  that  appears  doomed  may  only  lose  a 
few  phalanges.  The  disease  may  appear  in  other  portions  of  the  body, 
as  in  patches  over  the  deltoids,  inner  aspect  of  the  calves,  the  heels, 
maleoli,  nates,  cheeks,  and  on  the  abdomen,  rarely,  however,  going  on 
to  gangrene.     The  genitals  and  tongue  are  exceptionally  attacked. 

Constitutional  symptoms  rarely  default.  Intermittent  hemoglobi- 
nuria, uremia  ^  with  diminished  urea  and  a  lessened  quantity  of  urine, 
and  uremic  convulsions  are  frequently  noted.  Attacks  of  colic  have 
been  met  with  during  the  angiospastic  attack.  There  is  no  fever  at 
any  period  except  from  coincident  febrile  disease.  Cerebral  disturbance 
is  very  common.  ^  Irritability,  depression,  aphasia,  unconsciousness, 
coma,  convulsions,  and  mania  have  all  been  noted.  The  kidney  symp- 
toms and  the  brain  disturbance  are  apparently  due  to  the  angiospasm, 
which  further  shows  in  the  narrowed  retinal  artery,  dimness  of  vision, 
occasionally  occurring  hebetude,  tinnitus,  ageusia,  and  iridoplegia. 

Course  and  Prognosis. — The  attacks  are  of  variable  duration  and 
intensity.  A  few  hours  is  usually  sufficient  for  the  local  syncope  and 
asphyxia  to  develop  and  subside,  but  ordinarily  another  exposure  to 
cold  or  the  incidence  of  any  mental  strain  or  physical  fatigue  occasions 
a  return.  When  gangrenous  changes  have  developed,  several  months 
are  usually  consumed  in  exfoliation  and  cicatrization,  as  the  process  is 
extremely  slow  and  healing  very  tardy.  In  infants  the  disease  is  of 
rapid  course  and  may  terminate  in  death  in  a  few  days.  In  older  patients 
recovery  is  the  rule,  but  uremia  may  cause  death. 

Diagnosis. — The  diagnosis   in  a  typical   case  is  not  difficult.     The 

1  Aitken,  "  Lancet,"  Sept.  26,  1896. 

^  Osier,  "  Amer.  Jour.  Med.  Sciences,"  Nov.,  1896. 


TROPHONE  UROSES.  511 

causes  of  ordinary  gangrene  are  lacking,  but  nephritis  may  be  present 
in  Raynaud's  disease.  Repeated  symmetrical  local  syncope,  followed 
by  regional  asphyxia  and  passing  away  in  a  few  hours,  can  scarcely  be 
mistaken.  Several  bouts  of  lesser  degree  usually  precede  the  gangren- 
ous variety,  often  appearing  during  the  winter  for  years  in  succession. 
Hemoglobinuria  or  retention  of  urea  greatly  assists  the  diagnosis. 

Treatment. — The  principal  indication  is  to  improve  the  nutrition 
and  reestablish  the  general  health.  Locally,  during  the  attack,  the  use 
of  warm  applications  is  indicated.  The  parts  may  be  wrapped  in  cotton 
and  the  temperature  properly  maintained  by  artificial  heat.  Trinitrin 
and  amyl  nitrite  sometimes  give  prompt  relief.  Morphin,  hypoder- 
matically,  is  sometimes  required  to  relieve  pain.  The  local  use  of  the 
constant  electric  current  has  been  much  advocated,  but  the  warm  salt 
solutions,  in  which  the  extremities  are  directed  to  be  immersed,  probably 
are  as  active  as  the  electricity.  Gushing  ^  strongly  recommends  the 
application  of  an  elastic  or  Esmarch  bandage  to  relieve  the  attack. 
When  the  bandage  is  removed,  the  parts  rapidly  fill  with  blood  and  the 
vascular  spasm  subsides.  The  treatment  of  the  gangrene  is  surgical, 
but  it  is  especially  needful  to  wait  for  the  demarcation  line,  as  it  often 
includes  comparatively  little  of  the  threatened  extremities. 

ACROPARESTHESIA. 

Schultze  first,  in  1890,  used  the  term  acroparesthesia  to  describe  a 
condition  which  had  previously  been  fully  recognized  by  Nothnagel, 
Bernhardt,  Putnam,  and  others.  It  occurs  generally  after  middle  life 
in  hard-working  women  who  have  the  hands  constantly  wet,  as  in  wash- 
ing and  scrubbing.  The  paresthetic  feeling  is  usually  a  tingling,  crawl- 
ing, or  burning  sensation,  sometimes  attended  by  decided  pain  and  most 
marked  night  and  morning  and  in  winter.  The  hands  are  usually  alone 
affected,  but  the  feet  may  participate.  The  fingers  may  be  rendered 
clumsy  and  awkward.  The  color  of  the  skin  is  usually  natural,  but 
may  be  pale,  whitened,  or  reddened.  Sensibility  is  commonly  objectively 
normal,  but  hyperesthesia  and  hypesthesia  have  been  observed.  Arteries, 
veins,  and  nerves  are  normal.  There  is  no  atrophy  of  muscles  or  integu- 
ment, but  occasionally  a  complaint  of  weakness.  The  disorder  is  not 
serious,  but  tends  to  chronicity  and  may  last  many  years.  Cassirer  ^ 
notes  only  12  men  in  162  cases;  and  106  out  of  129  cases  occurred 
between  the  ages  of  thirty  and  sixty.  All  occupations  attended  by  ex- 
posure to  cold  and  dampness  are  represented.  The  climacteric,  alcoholism, 
influenza,  parturition,  and  uterine  extirpation  are  also  noted  as  causal. 
The  paresthesia  is  never  limited  to  the  distribution  of  a  given  nerve,  but 
usually  affects  all  the  digits  about  equally,  may  extend  to  the  elbows  or 
even  to  the  shoulders,  and  is  bilateral  as  a  general  rule.  The  feet  are 
also  affected,  but  less  frequently  and  less  severely. 

The  diagnosis  must  exclude  Raynaud's  disease,  nuiltiple  neuritis, 
and  scleroderma. 

1  "Jour.  Nerv.  and  Ment.  Dis.,"  Nov.,  1902. 

^  "Die  Vasoraotorisch-trophischen  Neurosen, "  Berlin,  1901. 


512  NEUROSES. 

The  prognosis  is  not  good  as  to  early  recovery,  but  favorable  as  to 
any  serious  resulting  condition. 

In  treatment  the  faradic  brush,  the  static  spark,  and  local  galvanism 
have  been  accredited  with  favorable  action.  General  measures,  tonics, 
hydrotherapy,  and,  most  of  all,  avoidance  of  occupational  causes  are 
mainly  to  be  relied  upon.  Collins  found  intestinal  disturbances  of  some 
sort  in  57  out  of  100  cases.  ^  All  such  conditions  require  unremitting 
attention. 

INTERMITTENT  LIMPING. 

A  condition  first  described  by  the  French  under  the  term  claudica- 
tion inter mittente,  has  been  designated  intermittent  limping  by  the  English, 
interrnittirende  Hinken  by  the  Germans,  angiosclerotic  paroxysmal 
myasthenia  by  Higier,^  and  angina  cruris  by  Walton.^  The  condi- 
tion is  manifested  in  pains  and  paresthesia,  generally  in  the  feet  and 
legs,  intensified  on  attempts  at  walking,  and  in  severe  cases  prevent- 
ing the  patient  advancing  more  than  a  few  steps  at  a  time.  Usually 
the  feet  are  more  comfortable  in  a  dependent  position,  and  in  some 
cases  the  patient  can  only  obtain  sleep  by  allowing  the  feet  to  hang  over 
the  edge  of  the  bed  or  by  sleeping  in  a  sitting  posture.  A  recurring 
lameness  has  been  long  known  to  veterinary  medicine  and  is  found  to 
be  due  to  disease  of  the  aorta,  generally  an  aneurism,  interfering  with 
circulation  in  the  hind  extremities.  In  the  human  race  it  is  always 
associated  with,  or  perhaps  one  should  say  is  the  manifestation  of  ineffi- 
cient circulation  in  the  legs  and  feet.  In  the  majority  of  instances  no 
pulse  can  be  obtained  in  the  dorsal  artery  of  the  foot,  and  in  a  large 
proportion  of  the  cases  the  posterior  tibial  is  also  pulseless.  The  pain, 
Avhich  is  the  chief  complaint,  is  manifested  in  three  different  conditions: 
(1)  Pain  upon  walking ;  (2)  permanent  pain,  frequently  in  the  form  of 
painful  paresthesia  while  the  patient  is  at  rest ;  (3)  the  pain  which 
initiates  true  gangrene. 

Goldflam  *  in  twenty-four  cases  found  the  disorder  at  twenty-five 
years  of  age  in  the  youngest,  but  usually  the  condition  develops  in  mid- 
dle life  and  rarely  after  fifty.  This  author  believes  that  the  pathological 
condition  is  usually  an  endarteritis,  although  it  is  but  seldom  that  any 
general  arterial  sclerosis  is  present.  Erb  has  insisted  upon  an  inherited 
disposition,  and  others  contend  that  there  is  a  congenitally  defective 
arterial  system.  The  abuse  of  tobacco  or  alcohol  has  been  rather  fre- 
quently noted  in  these  cases,  but  the  withdrawal  of  either  or  both  toxic 
factors  does  not  appear  to  better  the  condition.  Syphilis  was  only  found 
once  in  the  twenty-four  cases  of  Goldflam.  The  condition  is  usually 
symmetrical,  and  in  a  few  instances  the  nerves  of  the  part  have  been 
found  histologically  changed  slightly,  presenting  those  variations  which 
are  encountered  in  an  arteriosclerosis.  Massaut  ^  has  reported  a  case 
in  which  the  upper  extremities  were  similarly  affected  in  a  woman  of 
twenty-four  and  no  arterial  pulse  could  be  found  in  either  arm.     The 

1  "  Med.  Rec.,"  May  31,  1902.  ^  "  Deut.  Zeit.  f.  Nervenheilk.,"  July,  1901. 

3  "Boston  Med.  and  Surg.  Jour.,"  April  3,  1902. 
*  "Neurol.  Centralb.,"  Mar.  1,  1901. 
^  "  Ann.  de  la  See.  med.-chir.  d'Anvens,"  Mar.,  April,  1901. 


TROPHONEUROSES.  513 

painful  paralysis  of  ,the  upper  extremity  recurred  upon  any  continuous 
use  of  the  parts.  In  the  majority  of  instances  the  feet  are  cold  or 
blanched,  but  in  some  cases  the  parts  are  intensely  reddened,  suggesting 
an  erythromeUilgia,  and  in  others  the  alternation  between  blanching  and 
redness  strongly  simulates  Raynaud's  disease.  It  is  not  unlikely  that 
the  three  conditions  may  be  combined. 

Medicinal  treatment  seems  to  have  little  value.  Even  the  alkaline 
iodids,  which  have  such  a  well-founded  reputation  in  chronic  arterial 
changes,  give  little  assistance.  Warm  baths,  massage,  electricity  in  the 
form  of  the  galvanic  current,  withdrawal  of  tobacco  and  alcohol,  rest 
and  general  physical  improvement  are  the  measures  to  be  adopted. 
Gangrene  when  once  it  appears  has  a  tendency  to  extend,  and  early 
amputation  is  generally  recommended. 

ANGIONEUROTIC  EDEMA. 

AngloneurotiG  edema,  otherwise  known  as  acttte  circumscr'ibed  edema, 
acitte  non-inflammatovy  edema,  giant  urticaria,  periodic  swelling,  giant  swell- 
ing, Quincke's  disease,  etc.,  was  first  definitely  described  by  Milton,  in 
1876,  as  giant  urticaria.  Dinkelacker  and  Quincke,  in  1882,  gave  promi- 
nence to  it  under  the  above  title.  In  1892  Collins  was  able  to  assemble 
seventy-five  cases  and  made  a  critical  digest  of  the  literature.  Since 
that  time  numerous  instances  have  been  reported  all  over  the  world. 
It  is  marked  by  acute  circumscribed  swellings  of  the  subcutaneous  or 
submucous  tissues,  often  presents  a  direct  heredity,  usually  appears  in 


Fig.  226. — Angioneurotic  edeiua  involving  the  lower  portion  of  the  face  in  a  very  spare  individual. 

those  of  a  neuropathic  diathesis,  is  often  periodic  or  recurrent,  and  is 
commonly  attended  by  gastro-intestinal  colics. 

Etiology. — The  most  active  predisposants  are  heredity  and  exhaust- 
ing conditions.     The  neuropathic  taint  may  show  itself  in  antecedent  or 
associated  neuroses  and  psychoses  in  the  family  or  in  the  patient,  or  by 
33 


514  NEUROSES. 

the  stigmata  of  degeneracy.  •  This,  however,  is  far  from  being  an  abso- 
kite  rule,  and  numerous  cases  give  no  clue  ^vhatever  to  the  origin  of  the 
neurotic  disturbance.  Direct  heredity  is  often  marked,  as  in  the  series 
reported  by  Osier, ^  in  which  the  disease  numbered  20  cases,  extending 
through  five  generations,  and  the  series  of  Milroy,^  showing  six  genera- 
tions and  22  cases  out  of  97  individuals.  Continued  mental  or 
physical  exhaustion  often  prepares  the  field  for  the  development  of  the 
vascular  neurosis.  The  greatest  number  of  cases  appear  early  in  adult 
life,  from  trv^enty  to  thirty-five  years  of  age ;  but  it  has  been  noted  in 
infancy,  or  in  the  marked  hereditary  cases  it  may  be  congenital,  as  in 
20  out  of  22  cases  of  Milroy.  Both  sexes  are  affected,  but  females 
somewhat  more  commonly  than  males.  In  several  cases  a  decided  gouty 
tendency  was  present.  The  urine  showed  a  diminished  quantity  of 
urea,  and  the  attacks  were  beneficially  modified  Ijy  reduction  of  nitro- 
genous diet. 

As  exciting  causes,  exposure  to  cold,  intestinal  disorders,  pubertv^, 
the  climacteric,  masturbation,  traumatism,  fright,  grief,  and  the  action 
of  toxic  agents,  such  as  tobacco,  alcohol,  and  malaria,  have  been  noted 
with  considerable  frequency.  In  some  instances  the  malarial  intoxica- 
tion has  caused  quotidian  or  tertian  attacks.  In  some  they  have  recurred 
every  seventh  or  twelfth  day.  Aside  from  such  periodicity  they  have  a 
tendency  to  develop  during  the  latter  half  of  the  nighty  when  the  circu- 
latorv  activity  is  at  its  minimum.  They  also  show  a  seasonal  increase 
in  winter  and  summer,  apparently  the  result  of  temperature  changes 
and  chilling  of  the  skin,  and  sometimes  they  follow  slight  blows. 

Symptoms. — The  swellings  of  angioneurotic  edema  generally 
appear  without  warning,  and  reach  their  maximum  in  a  few  minutes  or 
in  an  hour  or  two.  The  most  usual  locations  are  the  face,  lips,  tongue, 
pharynx,  genitals,  and  extremities.  Tlie  hands  are  frequently  affected. 
The  buttocks,  shins,  or  abdomen  may  be  selected.  The  swelling  is 
tense,  sharply  defined,  not  tender,  does  not  pit  on  pressure,  is  whitish 
or  pinkish,  and  rarely  marked  by  purpuric  discolorations.  It  lasts  from 
a  few  hours  to  several  days,  and  vanishes  as  rapidly  as  it  appears, 
leaving  no  trace,  or  as  it  leaves  one  locality  a  similar  swelling  may  show 
itself  elsewhere  without  symmetrical  or  anatomical  relation.  Several 
swellings  may  appear  at  once.  In  amount,  the  swelling  varies  greatly, 
but  may  attain  large  proportions ;  hence  the  name  giant  swellings. 
Sometimes  nodular  swellings  as  large  as  hen's  eggs  are  encountered.  There 
is  usually  a  subjective  feeling  of  tension  and  stiffness  in  the  parts,  a^nd 
some  burning,  prickling,  or  itching.  If  the  skin  is  scratched,  urticarial 
stripes  and  wheals  usually  appear,  or  they  may  attend  the  attack  or 
alternate  with  it. 

The  tongue,  larynx,  pharynx,  stomach,  and  intestines  are  sometimes 
affected  by  the  swelling,  and  local  discomfort  and  even  serious  danger 
to  life  may  result.  Dyspnea,  difficult}"  of  swallowing,  intestinal  and 
gastric  colic  are  thus  induced,  and  several  cases  have  perished  from 
the  laryngeal  occlusion.      Gastro-intestinal  symptoms  are  very  common 

1  "Amer.  Jour.  Med.  Sciences."  .April.  1R88. 

2  "New  York  Med.  Jour.,"  Nov.  5,  1892. 


TROPHONEUROSES.  5 1 5 

and  appear  in  from  one-half  to  one-third  of  the  cases.  A  feeling  of 
uneasiness  in  the  epigastrium  is  followed  by  distention,  nausea,  and 
obstipation.  Colic,  cramps,  profuse  vomiting,  and  intense  thirst  ensue. 
The  attack  terminates  with  a  colliquative  diarrhea.  There  is  often  a 
great  increase  in  the  urinary  excretion  during  the  attack,  and  albuminuria 
and  hemoglobinuria  are  not  infrequently  encountered.  An  effusion  into 
the  joints  sometimes  takes  place.  The  attacks  may  come  on  at  various 
intervals  of  days,  weeks,  or  months,  or  with  regularity,  and  ordinarily 
between  the  attacks  the  previous  general  condition  of  health  is  regained. 
A  blow  is  sufficient  to  induce  and  locate  a  swelling  in  some  cases,  and 
there  is  a  tendency  for  the  swelling  to  recur  constantly  in  the  same 
locations.  In  some  of  the  congenital  cases  the  swelling  is  practically 
permanent,  general  as  well  as  intestinal  symptoms  being  absent. 

Diagnosis. — The  diagnosis  can  present  little  difficulty  if  one  is  on 
guard.  We  must  differentiate  the  erythematous  nodosities  of  rheu- 
matism, the  persistent  blue  and  white  edemata  of  hysteria,  and  the 
edemata  of  renal  and  cardiac  origin. 

Prognosis. — There  is  little  danger  unless  the  larynx  be  affected, 
and  there  is  a  general  tendency  for  the  attacks  to  cease  in  advanced 
years,  though  sometimes  they  last  for  life,  or  may  reappear  after  a  long 
interval.  If  traceable  to  inciting  causes,  the  immediate  prognosis  is 
improved.  If  dependent  upon  toxic  conditions  due  to  alcohol,  tobacco, 
malaria,  lithemic,  or  gastro-intestinal  infection,  the  proper  intervention 
promises  good  results. 

Treatment. — If  the  cause  can  be  discovered  and  removed,  the 
neurosis  promptly  yields.  Otherwise  reliance  must  be  placed  on  those 
general  measures  which  are  fitted  to  combat  the  neuropathic  constitution 
and  build  up  the  usually  depraved  systemic  condition.  The  treatment 
of  the  attack  is  symptomatic.  Morphin  for  gastro-intestinal  crises,  heat 
and  compression  to  the  swelling,  and  tracheotomy  or  intubation  if 
respiratory  failure  is  seriously  threatened. 


LOCALIZED  HYPERTROPHIES. 

Symmetrical  Lipomatosis. — Occurring  commonly  in  adults,  and 
usually  on  a  background  of  syphilis  or  alcoholism,  are  cases  manifesting 
localized  and  symmetrical  fatty  deposits.  These  may  be  tender  and  the 
seat  of  spontaneous  pain  or  comparatively  insensitive,  and  the  pain  mav 
be  quite  insignificant.  Their  favorite  location  is  about  the  neck,  the 
diffuses  Lipoma  des  Halses  of  the  Germans  ;  over  the  body,  as  in  the 
case  of  Hugier,  which  presented  twenty  symmetrical  pairs;  in  the 
axillae  and  groins  ;  or  on  the  extremities,  as  in  the  case  reported  by 
Mathieu,  one  pair  over  the  trochanters,  one  pair  on  the  inner  side  of 
the  knees.  The  adiposis  dolorosa  of  Dercum,  the  cases  of  Peterson 
and  Loveland,  and  the  adenolipomatosis  of  Launois  and  Bensaude  ^ 
(Fig.  228)  appear  to  belong  to  the  same  group.  Peterson,  Collins,  and 
others  look  upon  the  condition  as  due  to  a  rudimentary  polyneuritis, 

1  "Noiiv.  Icon,  de  la  Salpet.,"  1900. 


516 


NEUROSES. 


and  the  idea  is  supported  by  the  common  history  of  alcoholic  addiction 
or  luetic  infection.  In  addition,  sciatic  neuritis,  herpes  zoster,  optic- 
nerve  symptoms,  and  other  distinct  indications  of  neuritic  affection 
have  been  found  in  association.  The  local  sensitiveness,  pigmentary  dis- 
turbances, and  muscular  flabbiness  and  weakness  point  the  same  way. 
In  certain  cases  the  reaction  of  degeneration  and  a  wasting  of  the 
thenar  muscles  have  been  seen.  Dercum  ^  has  finally  demonstrated  an 
interstitial  neuritis.  This  has  been  confirmed  by  Burr,^  and  both  found 
suggestive  changes  in  the  thyroid  gland.  A  neuropathic  tendency 
can  frequently  be  traced.     The  condition  has  been  mistaken  for  myx- 


Fig.  227. — Symmetrical  lipomata;  tliree  pairs,  one  over  mastoids,  one  over  maxillary  articulations,  one 

under  augle  of  jaw  (Beck). 


edema  in  instances  marked  by  diffuse  lipomatosis,  but  the  hands,  feet, 
and  face  are  spared.  It  is  of  interest  to  remember  that  in  five  cases 
a  diseased  condition  of  the  thyroid  has  been  found  post  mortem.  ^ 

The  ill-defined  fatty  masses  are  commonly  spread  out  at  their  borders 
into  the  surrounding  tissue.  They  may,  however,  be  globular  or  pyri- 
forra  and  pendent.      Their  common  location  is  subdermal. 

In  slighter  cases  discontinuance  of  the  use  of  alcohol  or  antiluetic 
treatment  has  caused  the  tumors  to  recede.  In  aggravated  cases  medical 
treatment  has  apparently  accomplished  little  or  nothing,  but  recourse 
to  thyroid  feeding  promises  more,  in  view  of  its  effect  on  obesity  and 
the,  at  least  occasional,  presence  of  disease  of  the  thyroid  in  these  cases. 
Surgical  removal  of  the  fatty  tumors  is  sometimes  indicated. 

1  "Jour.  Nerv.  and  Ment.  Dis.,"  Aug.,  1900.  ^  jj,-^^  Oct.,  1900. 

^  Dercum  and  McCarthy,  "  Amer.  Jour.  Med.  Sciences,"  Dec,  1902. 


TROPHONEUROSES.  517 

Unsymmetrical  Hypertrophies. — In  rare  instances,  usually  con- 
genital, and  frequently  of  neurotic  ancestry,  one  side  of  the  body  or 
one  extremity,  or  a  portion  of  an  extremity,  as  a  hand  or  one  or  more 
digits,  may  be  disproportionately  large.  The  asymmetry  usually 
increases  with   the   child's  growth.      In  still  rarer  cases   it  makes  its 


Fig.  228. — Symmetrical  adenolipomatosis  (Launois  and  Bensaude). 

appearance  after  birth,  and  may  occur  at  any  time  up  to  maturity.  The 
hypertrophy  usually  involves  the  affected  portions  en  masse,  so  that  the 
increase  in  length  is  proportionate  to  the  breadth  and  thickness.  The 
principal  increase  is  usually  in  the  adipocellular  tissue,  but  the  muscles 
may  be  hypertrophic  and  may  show  correspondingly  increased  strength. 


518  NEUROSES. 

Usually,  however,  the  muscles  are  defective.  The  bones  are  simply 
enlarged.  Sometimes  the  hypertrophied  parts  are  warmer  than  their 
normal  fellows  and  may  show  increased  perspiration  and  evidences  of 
hyj)eremia.  Occasionally  there  are  pigmentary  markings.  Hemihyper- 
trophy  of  the  face  may  be  encountered,  and  Friedreich  reports  a  case 


Figs.  229,  230.— Adiposis  dolorosa  of  the  dlffase  truncal  form  (Dercum).  Fig.  229  shows  the 
peculiar  apron  of  fat  aud  the  small  size  of  the  hands.  The  po.sterior  view  shows  the  arrangement  of  fat 
in  folds  over  the  hips. 

y)resenting  hypertrophied  left  face  and  arm  and  right  leg.  In  rare 
instances  .such  localized  hypertrophies  are  seen  in  gigantism  and  acro- 
megalia. Of  their  nature  we  know  ])ractically  nothing.  In  some 
instances  it  has  been  attempted  to  check  the  overgrowth  by  compressing 
the  arterial  supply  and  bv  the  injection  of  astringents,  but  no  good 
seems  to  have  resulted.     Enlarged  digits  may  be  amputated. 


TROPHONEUROSES. 


519 


Chronic  Hereditary  Tropho-edema. — Henry  Meige  ^  describes  a 
family  in  which  edema  affected   eight  members,  both  men  and  women, 


Fig.  231. — Macrodactyly  :  localized  hypertrophy  of  a  single  finger  (Ridlon). 

distributed  through  four  generations.     Four  of  these  cases  were  observed, 
and  present  the  same  singular  affection  :  namely,  a  chronic  white,  firm, 


Fig.  232.— Chronic  hereditary  tropho-edema  in  sisters  at  seventeen  and  twenty-one  years  of  age  (Meige). 

and   painless   edema,  appearing  at  the  age   of   puberty,    and   affecting 

•especially  the  feet  and  legs  and  sometimes  the  entire  lower  members, 

1  "Nouv.  Icon,  de  la  Salpet.,"  Dec,  1899. 


520  NEUROSES. 

generally  on  both  sides.  He  also  refers  to  a  remarkable  family  reported 
by  Milroy,^  in  which  in  six  generations  there  were  twenty -two  cases. 
Other  similar  family  groups  have  been  published,  and  A.  Thomas 
thinks  that  one-sided  hypertrophies  of  the  body  belong  to  the  same 
category. 

The  condition  in  all  known  instances  has  caused  but  little  inconveni- 
ence, has  been  attended  by  no  suffering,  has  not  shortened  life,  and  has 
resisted  all  forms  of  treatment. 

1  "New  York  Medical  Eec,"  1893. 


INFECTION  NEUROSES.  521 


CHAPTER   II. 
INFECTION  NEUROSES. 

The  diseases  now  temporarily  grouped  among  the  neuroses  because 
the  essential  histological  lesions  of  the  nervous  apparatus  still  escape  us, 
but  due  to  the  action  of  infections,  are  tetanus  and  hydrophobia,  tetany 
and  chorea.  In  the  two  former  the  infection  is  capable  of  exj)erimental 
propagation  ;  in  the  latter  two  the  nature  of  the  poison  is  as  yet  an  infer- 
ential matter.  All  four  present  a  preponderance  of  motor  symptoms. 
Tetanus  and  hydrophobia  are  properly  surgical  conditions,  and  will  be 
very  briefly  outlined. 

TETANUS. 

Tetanus  is  an  acute  infectious  disease  marked  by  tonic  spasms  of  the 
voluntary  muscles,  usually  commencing  in  those  of  the  jaws  ;  hence  the 
names  trismus  and  lockjaw. 

Etiology. — The  disease  is  comparatively  more  common  in  hot 
climates  and  in  the  colored  races  than  among  Caucasians  in  temperate 
and  cold  regions.  This  may  have  relation  to  the  better  protection  by 
footwear  and  clothing  in  the  latter  conditions.  It  spares  neither  age 
nor  sex,  and  is  a  common  disease  among  horses.  It  may  occur  endemic- 
ally.  It  is  probably  always  introduced  traumatically,  and  can  usually 
be  traced  to  inoculation  by  objects  contaminated  by  the  ground-soil,  in 
which  the  bacillus  of  tetanus  readily  lives.  Naturally,  the  hands  and 
feet  are  the  most  common  locations  of  such  contaminated  abrasions  or 
more  extensive  lesions.  The  bacillus  first  discovered  by  Nicolaer,  and 
cultivated  by  Kitasato,  is  an  anaerobic,  drumstick-shaped,  motile  microbe. 
Culture  filtrates  contain  tetanizing  poisons  which  are  active  when  inocu- 
lated, but  not  when  ingested.  Experimental  evidence  indicates  that, 
like  strychnin,  their  action  is  mainly  upon  the  spinal  cord.^ 

Morbid  Anatomy. — The  condition  of  the  wound  presents  nothing 
characteristic,  and  in  the  brain  and  spinal  cord  the  congestion,  perivas- 
cular exudation,  small  hemorrhages,  and  pigmentation  of  cells  some- 
times encountered  are  neither  constant  nor  distinctive.  They  may  even 
be  looked  upon  as  the  results  of  the  spasmodic  conditions  that  mark  the 
clinical  course  of  the  infection.  The  same  is  true  of  the  serous  ecchy- 
moses,  pulmonary  congestions,  and  muscular  ruptures. 

Symptoms. — From  two  to  twenty  days  or  more  after  inoculation 
the  first  symptoms  appear.  The  intensity  of  the  disease  and  its  fatality 
are  usually  in  direct  proportion  to  its  early  onset.  Stiffness  of  the  neck- 
and  jaw-muscles  first  appears,  limiting  mastication,  the  movement  of 
the  tongue,  and  of  the  head.  Malaise,  chilly  sensations,  or  rigors  may 
antedate  the  muscular  stiffness,  but  usually  do  not  attract  much  attention. 

1  Wasserman  and  Takaki,  "  Berlin,  klin.  "Wochens.,"  June  3,  1898. 


522  NEUROSES. 

The  muscular  spasm  increases  in  intensity  and  invades  the  face  and 
trunk.  From  the  tonic  action  of  the  zygomatic  group  the  angles  of  the 
mouth  are  retracted  in  the  characteristic  sardonic  grin  that  uncovers  the 
teeth,  and  the  jaws  can  be  only  slightly  separated  or  may  be  quite 
immovable.  The  head  is  then  retracted,  and  the  entire  back  may  be 
aifected,  causing  rigidity,  or,  in  greater  degree,  opisthotonos.  In  some 
cases  the  trunk  is  bent  laterally  or  forward.  The  lower  extremities  are 
usually  more  affected  than  the  upper,  and  the  forearm  and  hands  are  last 
and  least  involved.  The  muscular  spasm  is  chiefly  tonic,  but  if  the 
condition  becomes  well  marked  there  are  sharp,  short,  convulsive 
exacerbations  that  may  reach  a  most  frightful  intensity.  They  are  then 
provoked  by  the  slightest  irritation,  such  as  a  sudden  noise,  a  bright 
light,  a  touch,  the  jarring  of  the  bed,  or  any  motor  effort.  They  may 
occur  a  few  times  a  day  or,  in  extreme  cases,  with  great  rapidity,  at 
scarcely  noticeable  intervals.  AVhen  these  develop  they  are  attended 
by  pain  proportional  to  their  intensity  and  duration.  They  may  impede 
the  thoracic  respiratory  excursions  or  induce  laryngeal  spasm  and 
dyspnea  or  asphyxia.  Often  the  thoracic  or  laryngeal  spasm  induces  a 
hoarse  noise,  which,  taken  with  the  distorted  face,  rigid  limbs,  retracted 
head,  and  opisthotonic  position,  presents  a  frightful  picture.  Profuse 
perspiration  may  be  occasioned.  The  temperature  may  be  normal, 
slightly  increased,  or  hyperpyrexia  may  appear  and  ordinarily  precedes  a 
fatal  termination.     Through  it  all  the  mind  remains  unclouded. 

Varieties. — Head  tetanus  or  cephalle  tetanus  follows  wounds  upon 
the  head,  face,  or  neck  ;  is  usually  of  prompt  appearance  after  the  inocu- 
lation ;  is  ordinarily  marked  by  trismus,  dysphagia,  facial  palsy,  and 
respiratory  difficulty,  a  rapid  course,  and  a  fatal  termination.  The  mod- 
ification of  tetanus  in  this  form  appears  to  be  due  to  early  poisoning  of 
the  medulla.  The  facial  palsy  that  frequently  and  the  oculomotor  pal- 
sies that  sometimes  occur  indicate  nuclear  disturbance.  The  difficulty 
in  swallowing  gives  a  rough  resemblance  to  rabies  and  has  led  to  the 
terra  tetanus  hydrophohiGus.  Tetanus  neonatorum  is  usually  due  to 
infection  of  the  umbilical  stump,  and  is  unknown  to  aseptic  midwifery. 
Puerperal  tetanus  occurs  in  parturients.  The  invasion  route  is  usually 
through  the  uterus. 

Diagnosis. — Given  a  locus  of  inoculation,  the  disease  can  scarcely 
be  mistaken.  When  a  history  of  trauma  is  wanting  hydrophobia  may 
be  suspected,  but  lacks  the  jaw-spasm  and  persistent  muscular  rigidity. 
Strychnin  poisoning  is  a  closer  imitator,  but  has  a  more  rapid  onset,  more 
violent  and  extensive  convulsions,  trismus  is  absent,  and  relaxation 
occurs  between  the  spasms.  Tetany  affects  the  hands  and  feet  mainly 
and  primarily  and  shows  a  number  of  special  reactions,  such  as  increased 
electrical  excitability  and  Trousseau's  sign.  Hysteria  may  imitate 
tetanus,  but  ordinarily  gives  a  hysterical  history  and  presents  the  stig- 
mata of  the  neurosis.  It  also  usually  appears  suddenly  after  a  hyster- 
ical convulsion,  suddenly  disappears  and  recurs,  and  lacks  the  nuchal 
rigidity  and  mental  clearness  of  tetanus.  Bacteriological  examination 
of  pus  from  wounds  may  make  or  confirm  the  diagnosis. 

Prognosis  is  always  grave  and  the  mortality  is  over  eighty  per  cent. 


INFECTION  NEUROSES.  523 

Cases  appearing  before  the  sixth  day  usually  die  ;  those  appearing  after 
the  twelfth  day  are  likely  to  recover.  Death  results  from  apnea  and 
heart-strain.  Favorable  indications  are  :  late  onset,  limited  muscular 
spasm,  absence  of  respiratory  and  medullary  symptoms,  infrequency  of 
convulsions,  normal  temperature,  and  ability  to  receive  and  assimilate 
nourishment. 

Treatment. — If  the  wound  of  entry  for  the  tetanus  infection  is  in 
an  unhealthy  state,  surgical  measures  of  local  disinfection  are  always  in 
order,  and  usually  consist  of  scraping,  cauterization,  and  the  employ- 
ment of  active  germicides.  Laml^ert  ^  believes  that  hydrochloric  and 
carbolic  acid  together  furnish  the  best  local  application.  It  often  hap- 
pens that  the  infection  atrium  is  completely  healed,  and  even  early 
cauterization  seems  to  be  of  doubtful  assistance  in  checking  the  disease. 
The  general  management  is  of  prime  importance.  The  patient  should  be 
secluded  in  a  darkened  room  and  every  possible  excitation  be  prevented. 
Alimentation  should  be  carefully  maintained  by  easily  digested  fluid 
foods,  and,  if  necessary,  by  the  use  of  the  nasal  tube  or  by  rectal  injec- 
tion. Sedative  drugs  and  antispasmodics  are  indicated,  and  various  ones 
have  cures  credited  to  them.  Chloroform  and  nitrite  of  amyl  are 
useful  to  meet  the  convulsions.  Chloral,  bromids,  morphin,  calabar 
bean,  and  curare  are  advised,  but  must  be  used  with  a  free  hand  or 
omitted  entirely.  Hot  baths  sometimes  act  most  soothingly.  Active  arti- 
ficial respiration  is  required  in  case  of  dyspnea  and  threatened  asphyxia. 
Immunization  of  late  years  has  been  attempted  by  the  use  of  the  anti- 
toxins introduced  by  Tizzoni  and  Catani.  They  have  been  found 
practical  and  reliable  in  animal  experiments.  There  is  much  diversity 
of  opinion  regarding  their  value  in  human  tetanus.  Kneass,^  from  a 
tabulation  of  sixty-one  cases  treated  by  tetanus  antitoxin,  finds  an  insig- 
nificant advantage  over  the  older  medicinal  methods,  and  Berger,  Houx, 
Yandell,  and  others  are  of  the  same  opinion.  Lambert  ^  states  a  mor- 
tality of  thirty-seven  per  cent,  under  the  antitoxin  in  acute  cases  devel- 
oping within  eight  days  of  the  infection.  It  is  not  unlikely  that  the 
antitoxins  will  be  so  much  improved  as  to  give  better  and  more  reliable 
results,  and  they  can  not  well  be  omitted  in  the  treatment  of  this  disease. 
They  are  valuable  in  proportion  to  their  early  use.  Antitoxin  has  been 
injected  into  the  substance  of  the  brain  through  trephine  openings  in 
order  to  bring  it  quickly  into  operation,  but  the  results  hardly  warrant 
the  method.  Intraspinal,  subdural,  intravenous,  and  subcutaneous  injec- 
tion are  less  objectionable  and  probably  equally  efficacious.  At  present, 
medicinal  preparations  are  also  imperatively  demanded  in  the  treatment 
of  tetanus. 


HYDROPHOBIA. 

Hvdrophobia  is  an  acute,  infectious  disease  of  carnivorous  animals, 
transmissible  to  man  and  to  other  animals  by  inoculation.      It  is  also 

^  "  Amer.  Jour.  Med.  Sciences,"  Aug.,  1897. 

2  "  Jour,  Am.  Med.  Association,"  Julj^  18,  1896.  ^  loc.  cit. 


524  NEUB0SE8. 

known  as  rabies  and  lyssa.  The  inoculating  animals  usually  are  dogs 
or  wolves,  but  the  cat,  skunk,  and  even  poultry  may  carr^'  the  disease. 
The  exact  nature  of  the  poison  is  unknown.  It  undoubtedly  is  a  living 
contagium.  The  disease  is  rare  in  this  country,  but  seems  to  be  growing 
more  common  in  the  Eastern  States,  and  almost  invariably,  in  man,  is  the 
result  of  bites  by  rabid  dogs.  In  North  Germany,  where  the  muzzling 
of  dogs  is  rigidly  enforced,  the  disease  is  almost  unknown.  It  is, 
therefore,  in  civilized  countries  a  preventable  disease. 

Morbid  Anatomy. — The  nervous  system  frequently  shows  lesions, 
but  these  may  be  completely  lacking  and  to  some  extent,  when  present, 
are  secondary  to  the  disease,  following  the  spasms,  dyspnea,  and  cardiac 
failure.  They  consist  essentially  of  vascular  disturVjances  :  dilatation, 
perivascular  leukocytal  infiltration,  ante-mortem  intravascular  clots,  and 
minute  hemorrhages.  Such  changes  are  most  frequently  encountered  in 
the  cortex  cerebri,  the  medulla,  and  cord.  According  to  Gowers,  they 
are  most  intense  in  the  neighborhood  of  the  pneumogastric  and  hypo- 
glossal nuclei.  The  perivascular  infiltration  in  this  locality  may  be 
intense  enough  to  suggest  miliary  abscesses.  The  salivary-  glands  and 
kidneys  frequently  show  a  similar  infiltration  and  the  mucous  membrane 
of  the  pharynx  and  larynx  is  commonly  congested. 

Symptoms. — Incubation  requires  a  variable  period  of  from  two 
weeks  to  six  months,  and  there  are  reported  cases  occurring  twelve  and 
even  eighteen  months  after  inoculation,  the  virus  having  remained 
dormant.  The  ordinary  incubation  period  is  six  weeks  to  two  months. 
The  length  of  incubation  time,  according  to  Horsley,  is  modified  by  a 
number  of  factors  :  (1)  It  is  shorter  in  children  than  in  adults.  (2) 
Wounds  of  the  face,  neck,  head,  and  hands,  and  the  unclothed  parts 
are  especially  dangerous,  and  the  disease  then  develops  promptly.  (3) 
Punctures  are  the  most  dangerous ;  lacerations  are  serious  in  proportion 
to  their  extent.  (4)  The  bites  of  rabid  animals  are  serious  in  this  order  : 
Wolf,  cat,  dog,  and  other  animals.  About  fifteen  per  cent,  of  the  persons 
bitten  by  dogs  known  to  be  rabid  develop  hydrophobia. 

Habies  varies  in  intensity  in  both  animals  and  man.  In  cases  of 
great  severity  paralytic  features  develop  early,  there  is  little  excitement, 
and  death  promptly  supervenes.  When  the  poisonmg  is  less  profound, 
the  disease  runs  a  longer  course,  and  presents  a  period  of  great  motor 
and  cerebral  excitement.  In  man  the  invasion  of  the  disease  is  fre- 
quently marked  by  irritation  about  the  wound,  with  pain  or  numbness. 
Usually  there  is  headache,  depression,  loss  of  appetite,  irritability, 
sleeplessness,  and  anxiety.  The  pulse  and  temperature  may  be  slightly 
increased.  Bright  lights,  noises,  and  slight  excitement  of  any  sort  are 
shunned  owing  to  the  increased  sensibilits",  Stifiness  of  the  throat- 
muscles  and  difficulty  in  swallowing  are  noticed.  A  period  of  excitement 
then  usually  develops,  when,  in  rare  instances,  the  central  apparatus  may 
be  overwhelmed  and  the  paralytic  form,  with  ascending  paraplegia  and 
heart-failure,  terminates  the  case  within  a  comparatively  few  hours.  In 
the  excited  period  there  is  great  motor  restlessness  and  hypersensibility  : 
spasms  affecting  the  throat  are  induced  by  any  fictitious  stimulus,  and 
swallowing  becomes  impossible,  so  that  fluids  are  shunned,  and  the  sight 


INFECTION  NEUROSES.  525 

of  them  may  even  become  unbearable  ;  hence  the  name,  hydrophobia. 
Noises,  lights,  a  breath  of  air,  may  provoke  the  spasm  ;  and  it  may 
involve  tlie  larynx  and  thorax,  producing  dyspnea,  cyanosis,  and  an 
alarming  asphyxia  that  even  tracheotomy  may  fail  to  relieve.  The 
respiratory  and  deglutition  spasms  are  often  attended  by  hoarse  sounds 
and  peculiar  noises,  that  have  been  thought  by  excited  laymen  to 
resemble  the  barking  of  dogs.  Saliva  accumulates  in  the  mouth  or 
drules  from  its  corners,  partly  from  an  increased  secretion,  but  mainly 
from  difficulty  in  swallowing.  Hallucinations  and  delirium  are  fre- 
quently present,  but  the  mind  may  be  quite  clear  and  the  patient  quiet 
between  the  paroxysms.  The  temperature  commonly  ascends  to  100° 
or  103°,  but  the  disease  may  be  afebrile  throughout.  The  spasms 
gradually  become  wide-spread  and  tetanoid,  but  rarely  affecting  the 
jaw  and  face,  and  relaxation  occurs  in  the  intervals.  After  one  to 
three  days  they  are  followed  by  the  paralytic  period,  and  spasms  no 
longer  occur.  An  ascending  paraplegia  is  commonly  presented.  Quiet, 
stupor,  and  coma  follow ;  the  heart's  action  becomes  greatly  weakened, 
and  death  follows  syncope. 

Diagnosis. — The  diagnosis  of  a  well-developed  case,  with  motor 
excitement  and  a  history  of  a  bite  by  a  rabid  animal,  can  be  readily 
made.  We  have  to  exclude  tetanus,  in  which  there  is  usually  a  very 
recent  trauma,  masticatory  spasm,  constant  rigidity,  and  little  or  no 
difficulty  in  swallowing.  Lyssophobia  is  a  hysterical  condition  occur- 
ring in  a  neurotic,  and  is  a  variety  of  hypochondriasis  with  the  fixed 
idea  of  rabies.  The  attacks  that  occur  are  hysterical  exaggerations  of 
the  newspaper  accounts  of  rabid  patients,  and  such  cases  can  usually 
be  deciphered  by  the  concomitant  indications  of  hysteria.  Every  such 
case  should,  however,  be  carefully  watched  if  it  is  reasonably  certain 
that  the  patient  has  been  bitten  by  an  animal  suspected  of  rabies.  In 
every  case  it  is  also  important  to  diagnose  the  condition  in  the  alleged 
rabid  animal,  and  this  can  be  done  with  certainty  if  inoculation  experi- 
ments can  be  made.  In  case  of  a  bite  by  a  dog,  the  animal  should  be 
placed  under  observation,  if  possible,  and  not  destroyed.  The  saliva 
being  highly  poisonous,  a  little  of  it  may  be  inoculated  into  the  dura  of 
a  dog  or  rabbit,  and  precise  results  obtained.  In  dogs,  the  paralytic 
form  of  rabies  is  the  most  common,  the  furious  form  exceptional.  The 
early  symptoms  in  the  dog  consist  of  dullness,  irritability,  and  surliness, 
the  bark  becomes  metallic,  food  is  neglected,  but  bits  of  wood,  dirt,  and 
other  indigestible  articles  are  sometimes  swallowed.  If  furor  develop 
the  dog  runs,  snapping  at  everything  in  its  way,  especially  attacking 
other  dogs.  Children,  being  unaware  of  danger  and  less  able  to  escape, 
are  more  frequently  bitten  than  adults.  After  a  day  or  two,  or  a  few 
hours  only  in  some  cases,  paralytic  symptoms  set  in.  The  animal  be- 
comes uncertain  on  its  legs,  the  hinder  limbs  give  way,  and  the  paraly- 
sis becomes  general,  ending  in  death.  The  excited  stage  is  commonly 
transient,  and  paralytic  conditions  promptly  develop. 

Treatment. — An  inoculated  wound,  or  one  reasonably  suspected, 
should  be  treated  locally,  at  the  first  possible  moment,  by  thorough  cau- 
terization, or  excision,  if  practicable.     The  use  of  a  ligature  above  the 


526  NEUROSES. 

wound  when  on  an  extremity,  suction,  and  free  bleeding  are  also  of 
value.  The  actual  cautery,  a  bunch  of  burning  matches,  strong  carbolic 
or  nitric  acid,  may  be  used.  Immunization  by  Pasteur's  method  is  now 
practicable  in  most  large  cities.  The  sooner  it  is  undertaken,  the  more 
successful  it  is  likely  to  be.  Less  than  one-half  of  one  per  cent,  of  all 
cases  treated  in  this  way  have  died  of  rabies.  When  hydrophobia  de- 
velops in  man,  about  the  same  treatment  is  required  as  in  tetanus. 
There  is  no  danger  to  attendants,  and  no  case  is  on  record  where  the 
disease  has  been  transmitted  from  man  to  man.  Forcible  physical  con- 
trol is  practically  never  needed.  If  food  and  drink  can  be  swallowed, 
it  should  be  freely  given,  but  rectal  alimentation  is  usually  required. 
Chloroform,  bromids,  morphin,  and  sedatives  are  palliative  only. 
The  disease  is  invariably  fatal. 


TETANY. 

Tetany,  or  tetanilla,  is  marked  by  peculiar  tonic,  bilateral,  parox- 
ysmal, muscular  contractions,  commencing  in  and  usually  confined  to 
the  extremities,  and  presents  an  increased  mechanical  and  electrical 
excitability  of  the  nerves.  It  may  occur  in  epidemics,  is  endemic  in 
many  places,  and  commonly  develops  on  a  background  of  malnutrition. 

Etiology. — It  occurs  most  frequently  before  twenty  and  practically 
never  after  fifty  years  of  age.  Both  sexes  are  aflPected,  males  more  fre- 
quently before  adult  life,  females  more  commonly  thereafter.  In  Paris, 
Berlin,  Prague,  Vienna,  and  in  Syria  it  may  be  considered  endemic,  and 
epidemics  of  it  have  been  noted  in  these  places,  and  in  schools  and  garri- 
sons. In  the  neurological  clinics  of  Berlin  ^  tetany  furnishes  one  per 
cent,  of  all  cases.  In  Vienna  seven-tenths  of  one  per  cent.  It  appears 
most  commonly  from  January  to  May.  In  America  it  is  comparatively 
rare  outside  of  quarters  in  large  cities  largely  populated  by  foreigners. 
Predisposing  causes  include  nearly  every  variety  of  depraved  nutrition. 
Sarbo,2  from  an  extensive  review  of  the  causes  of  tetany,  asserts  that 
impaired  nutrition  is  the  only  common  factor.  Of  most  importance  are 
chronic  gastro-intestinal  disorders,  especially  gastric  dilatation,  with 
hyperacidity,  fermentative  diarrhea,  and  chronic  constipation.  Pickets 
is  a  very  common  accompaniment  in  children.  Cassel  ^  found  it  in  58 
out  of  60  cases.  Tetany  may  follow  acute  infectious  and  septic  pro- 
cesses, or  appear  during  pregnancy  or  lactation.  Enucleation  of  the  thy- 
roid has  been  followed  by  tetany  in  a  considerable  proportion  of  case's. 
Billroth  and  Wolfler  reported  19  cases  of  tetany  in  a  toM  of  123 
thyroidectomies.  There  is  a  certain  relation  between  tetany  and  myx- 
edema, which  may  concur  in  a  given  case.  If  about  one-fifth  of  the 
thyroid  is  spared,  tetany  does  not  appear,  according  to  von  Eiselberg. 
Murray  insists  that  it  does  not  occur  if  the  parathyroid  is  spared.  As 
exciting  causes  of  the  paroxysmal  attacks,  exposure  to  cold  and  emo- 

^  Lathrop,  "Boston  Med.  and  Surg.  Jour.,"  Nov.  19,  1896. 

2  "Deut.  Zeit.  f.  Nervenheilk.,"  1896. 

3  "Deut.  med.  Wochen.,"  Jan.  28,  1897. 


INFECTION  NEUROSES. 


527 


active,  as  are  overexertion,  exhaustion, 
The  administration  of  ergot,  chloroform, 
to  appear,  and  they  may  be  induced  by 
nerve-trunks   and    blood-vessels,   in   the 


tional  disturbances  are  often 
acute  diarrhea,  and  vomiting, 
and  alcohol  has  caused  them 
mechanical   irritation   of  the 
manner  to  be  described  later. 

The  epidemic,  endemic,  seasonal,  remissive,  and  toxic  features  of  the 
disease  point  very  strongly  to  the  activity  of  some  zymotic  agent,  but  as 
yet  it  has  escaped  detection.  Oddo  ^  suggests  that  it  may  only  be  active 
in  the  presence  of  some  special  form  of  perverted  digestion.  The  vul- 
nerable portion  of  the  nervous  system  appears  to  be  the  spinal  and  bul- 
bar gray  and  the  peripheral  nerves.  Morbid  anatomical  changes  are  not 
constant,  though  suggestive.  Cloudiness  and  swellings  in  the  anterior 
horns  have  been  noted  by  Weiss  and  by  Barome  and  Cervasato.  The 
clinical  manifestations  mainly  fall  within  the  domain  of  the  louver  motor 
neurons. 

Symptoms. — The  first  thing  to  attract  the  patient's  attention  is  the 
development  of  spasmodic  stiffness,  usually  first  appearing  in  the  fingers 
and  wrists.  After  the  recurrence  of  several  attacks  adults  sometimes  rec- 
ognize in  malaise,  headache,  depression,  and  general  pains,  premonitions 
of  the  on-coming  rigidities.  The  attacks  are  initiated  by  a  feeling  of 
prickling,  numbness,  and  some  local 
pain.  The  spasm  comes  on  slowly  and 
increases  gradually  in  intensity,  accom- 
panied by  growing  discomfort  and  pain 
in  the  muscles.  There  are  no  mental 
features  attributable  to  tetany.  The 
spasms  begin  peripherally  in  the  fingers 
and  toes,  and  advance  toward  the  trunk. 
Ordinarily,  they  are  limited  to  the 
limbs,  and  mainly  affect  the  parts  be- 
low the  elbows  and  knees.  The  upper 
extremities  may  alone  be  invaded.  In 
other  cases  the  tonic  spasm  reaches  the 
roots  of  the  limbs  and  invades  the 
trunk,  and  may  involve  all  the  body- 
muscles  in  very  severe  cases.  Retrac- 
tion of  the  head  and  strabismus  are 
seldom  encountered.  The  contraction 
is  tonic  in  character  and  usually  per- 
sistent during  the  attack,  but  may 
intermit.  The  attack  may  last  from  a 
few  minutes  to  many  hours  and  occur 

several  or  many  times  daily.  Attacks  may  cease  for  intervals  of  days, 
weeks,  or  months,  and  then  reappear,  but  if  latent  they  can  be  provoked 
in  the  intervals  by  appropriate  manipulation. 

The  positions  and  attitudes  caused  by  the  spasms  of   tetany  are 

strikingly  peculiar.    Ordinarily,  the  hands  are  rolled  into  the  cone-shape 

of  the  accoucheur,  the  digits  flexed  at  the  metacarpal  joints  and  rigidly 

extended   at  the   interuodal   articulations,    the   thenar  and   hypothenar 

1  "Miinch.  med.  Wochen.,"  Nov.  10,  1896. 


Fig.  233.— Infant  with  mild  attack  of 
tetany,  sliowing  chaiacteristic  spasmodic 
position  of  hands  and  feet. 


528  NEUBOSES. 

eminences  approximated.  The  wrist  may  also  be  flexed  and  the  hand 
drawn  to  the  uhiar  side.  Less  commonly  the  fingers  and  wrists  are 
extended,  or  the  hand  may  be  made  into  a  fist  grasping  the  thumb,  or 
the  thumb  may  protrude  between  the  index  or  middle  digits.  In  cases 
of  severity  the  elbows  are  flexed  and  adducted  strongly  against  the  body. 
The  fed,  when  affected,  present  a  forced  equino  varus  position,  with  flexed 
and  sometimes  overlapping  toes.  In  extreme  cases  there  is  flexion  at 
the  knees  and  hij)s.  The  muscles  of  the  forearms,  legs,  hands,  and  feet 
are  tense,  firm,  and  often  sensitive.  Voluntary  movements  in  the  parts 
are  impossible,  and  passive  motion  causes  pain.  When  the  spasm  in- 
vades the  trunk,  intercostal,  abdominal,  and  spinal  rigidity  may  appear 
and  breatking  be  impeded.  In  rickety  children  laryngismus  stridulus  is 
not  uncommon ;  in  adults  laryngeal  spasm  constitutes  a  serious  compli- 
cation. In  rare  instances  spasm  in  the  neck-muscles  draws  down  the 
chin  and  the  angles  of  the  mouth,  and  has  even  produced  fatal  com- 
pression of  the  air-passages.  Solovieff  ^  has  noticed  in  adults  rhythmic 
contractions  of  the  diaphragm  synchronous  with  the  heart-beat  and 
attended  by  a  whistling  sound  in  the  left  lung.  Thoracic  and  diaphrag- 
matic rigidity  may  induce  asphyxia  and  even  death.  Ordinarily,  the 
face  escapes.  The  sphincters  may  be  tonically  contracted,  inducing 
obstipation  and  anasarca,  according  to  Oddo  and  Sarles,^  who  also  noted 
indican  in  the  urine,  due  to  intestinal  fermentation,  and  confirmed 
Weiss'  observations  of  the  hypertoxicity  of  the  urine.  Retention  of 
urine  may  be  the  most  prominent  symptom.  ^ 

The  electrical  and  mechanical  irritability  of  the  motor  nerves  is 
peculiarly  increased.  If  pressure  be  made  over  the  median  or  ulnar 
nerves,  the  spasm  in  the  hand  is  increased,  or  during  its  absence  is  pro- 
voked. Pressure  over  the  brachial  artery  may  have  the  same  effect. 
This  is  known  as  Trousseau's  sign,  and  is  practically  pathognomonic. 
Gentle  tapping  on  the  nerves,  as  with  a  percussion  hammer,  has  the 
same  effect.  Chvostek  discovered  that  the  facial  nerve  could  be  aroused 
in  the  same  manner,  causing  a  facial  contortion  exactly  limited  to  the 
distribution  of  a  branch  or  of  the  entire  nerve,  depending  upon  the  loca- 
tion of  the  blows — Chvostek's  sign.  Erb  first  described  a  peculiar  exal- 
tation of  the  electical  excitability,  especially  to  the  galvanic  current — i>6's 
phenomenon.  A  single  cell,  giving  but  one  or  two  milliamperes  of  cur- 
rent, may  be  sufficient  to  provoke  sharp  contractions,  and  anodal  opening 
tetanus  (A.  O.  Te.)  is  found  in  this  disease  alone.  Sarbo  has,  in  a  single 
case,  noted  the  myotonic  reaction  in  the  triceps,  a  response  that  was  con- 
sidered confined  to  Thomsen's  disease.  It  consists  of  persistent  confrac- 
tion,  lasting  some  moments  after  cessation  of  the  galvanic  current.  The 
faradic  responses  are  also  accentuated  in  most  cases,  but  may  remain 
about  normal.  Pressure  upon  the  nerves  is  more  than  ordinarily  pain- 
ful, and  readily  induces  persistent  paresthesia  in  their  cutaneous  distri- 
bution. The  tapping  that  causes  spasm  also  induces  pain.  Edema  of 
the  hands  and  feet  and  localized  perspiration  may  be  encountered.  The 
temperature  may  be  normal,  but  is  often  elevated,  as  might  be  expected, 
in  the  gastro-intestinal  cases,  and  subnormal  in  the  arthyroidal  state  of 

1  " Eousski  Vratch,"  1902.  ■""!,&  Med.  Inf.,"  Sept.  15,  1894. 

sBurkhardt,  "  Jahrsb.  f.  Kinderh.,"  1899. 


INFECTION  NEUROSES.  529 

operative  myxedema.  Auditory  and  optic  symptoms  and  trophic  changes 
in  the  muscles  are  found  only  as  accidents.  Objectively,  cutaneous 
sensibility  is  normal  and  the  reflexes  are  unchanged  except  when  in- 
hibited by  the  spasmodic  state  of  the  muscles. 

Course. — The  great  majority  of  cases  run  a  mild  course  to  recovery 
in  a  few  weeks,  especially  if  the  underlying  cause  can  be  removed,  but 
when  tetany  develops  on  gastric  dilatation  or  chronic  catarrhal  enteritis 
it  is  likely  to  have  a  protracted  course.  Appearing  generally  when  the 
organism  is  already  depressed  by  malnutrition,  it  may  be  a  formidable 
complication,  and  in  the  severe  cases,  where  the  spasms  invade  the  trunk 
and  implicate  the  respiratory  apparatus,  death  by  asphyxia  may  result. 
In  pregnancy  it  is  likely  to  be  mild  and  usually  terminates  promptly 
after  delivery,  but  parturition  may  cause  veiy  severe  exacerbations  of 
the  attack.  The  lactational  cases  are  usually  manageable  if  the  child 
be  weaned  and  the  nutrition  of  the  patient  reestablished.  Tetany  in 
the  athyroidal  state  is  frequently  fatal ;  it  may  be  permanent  and  excep- 
tionally it  yields  to  thyroid  feeding.  Only  when  Trousseau's  and 
Chvostek's  signs  fail  can  the  disease  be  considered  at  an  end.  In  fatal 
cases  the  spasms  increase  in  frequency,  distribution,  and  intensity,  and 
asphyxia  destroys  the  patient,  but  death  in  tetany  is  more  commonly 
the  result  of  the  underlying  disease. 

Diagnosis. — The  diagnosis  is  easy  if  the  characteristic  spasms  are 
accompanied  by  the  mechanical  and  electrical  overexcitability  of  motor 
and  sensory  nerves.  We  have  to  exclude  tetanus,  in  which  the  spasms 
are  preceded  by  stiffness  in  the  masseters  which  does  not  subside  in  the 
intervals  between  the  spasms.  It  is  also  marked  by  nuchal  rigidity  and 
great  general  irritability.  In  tetanus  the  spasm  is  propagated  toward 
the  extremities,  usually  sparing  the  hands  ;  in  tetany  it  is  centripetal 
and  usually  begins  in  the  hands.  The  phenomena  of  Trousseau, 
Chvostek,  and  Erb  are  absent  in  tetanus.  Hysteria  also  lacks  these 
special  signs  and  has  its  own  stigmata.  Meningitis  may  be  mistaken  in 
infants,  but  presents  none  of  the  special  signs  of  tetany. 

Prognosis. — The  prognosis  is  usually  good,  but  hangs  upon  the 
nature  and  manageability  and  the  underlying  cause.  It  is  unfavorable 
in  proportion  to  the  extent  and  degree  of  malnutrition  present.  It  is 
grave  in  the  athyroidal  cases,  which  present  a  mortality  of  about  eighty 
per  cent.  A  tendency  to  recurrence  upon  renewal  of  the  predisposing 
state  is  marked.  Thus,  some  women  present  tetany  in  several  successive 
pregnancies,  and  exacerbations  of  the  predisposing  gastro-intestinal  state 
may  incite  a  return  of  the  tetany.  Extreme  severity  of  spasms,  involve- 
ment of  the  respiratory  apparatus,  intense  manifestation  during  labor, 
and  cerebral  symptoms,  as  in  uremic  cases,  are  of  serious  import. 

Treatment  must  be  directed  to  the  removal  of  the  underlying  causal 
■state,  but  it  is  rarely  necessary  to  interrupt  pregnancy.  Rickets,  gastric 
dilatation,  intestinal  catarrh,  intestinal  parasites,  and  lactation  have  their 
several  indications.  Hygienic  and  sanitary  conditions  must  be  atten- 
tively studied.  The  sjmsms  are  controlled  by  quiet,  rest,  and  warm 
baths.  Bromids  and  chloral  are  useful  in  the  interval,  but  morphin, 
and  even  chloroform,  may  be  required  for  the  attack.  When  this  coin- 
34 


530  NEUROSES. 

cides  with  labor,  the  birth  must  be  hastened.  Chloroform  must  be  used 
with  circumspection,  as  it  may  provoke  laryngeal  spasm,  as  may  also 
the  employment  of  the  stomach-tube  in  gastric  cases.  In  the  athyroidal 
cases  thyroid  feeding  sometimes  gives  relief,  but  can  not  be  relied  upon. 
The  administration  of  thyroids  in  other  cases  may  also  be  tried.  Mass- 
age, electricity,  and  passive  movements  must  be  avoided,  as  they  usually 
intensify  the  spasms  when  present,  and  provoke  them  if  absent.  A  hot 
sponge  over  the  larynx  may  relieve  laryngeal  spasni,  but  tracheotomy 
may  be  required  in  rare  instances.  Oddo  ^  attaches  much  value  to  the 
continuous  use  of  calomel,  which  corrects  the  gastro-intestinal  fermenta- 
tion and  expels  toxic  substances.  Dietetic  regulations  are  often  of  the 
first  importance.  The  condition  of  the  bladder  should  be  watched  and 
excessive  retention  of  urine  prevented. 

CHOREA.* 

It  is  desired  to  limit  the  term  chorea  to  a  definite  morbid  entity. 
The  choreiform  features  of  hysteria  which  mark  epidemics  of  St.  Vitus' 
dance,  hereditary  chorea,  or  the  so-called  chorea  major  of  Huntingdon, 
the  electric  chorea  of  Dubini,  habit  chorea  or  the  maladie  des  tics,  and 
the  various  forms  of  myoclonus  should  be  carefully  distinguished  from 
minor  chorea  or  the  chorea  of  Sydenham,  with  which  we  are  now  to  deal. 
It  is  commonly  called  St.  Vitus'  dance,  but  that  term  may  better  be  re- 
served for  the  hysterical  forms. 

"  Chorea,"  judicially  says  Osier,  ^  "  is  an  acute  disease  of  childhood, 
rarely  of  adults  and  of  the  aged.  Characterized  by  irregular,  involun- 
tary movements,  a  variable  amount  of  physical  disturbance,  and  asso- 
ciated very  often  with  arthritis  and  endocarditis.  The  disease  is  usually 
considered  as  a  neurosis,  but  the  clinical  characters  of  the  severe  cases 
and  the  frequent  heart  and  joint  complications  have  suggested  to  many 
recent  writers  that  it  may  be  due  to  a  specific  poison." 

Etiology. — Predisposing  Causes — Sex. — Girls  are  affected  somewhat 
more  than  twice  as  frequently  as  boys,  and  the  disproportion  becomes 
even  greater  after  puberty.  The  vast  majority  of  cases  develop  between 
five  and  sixteen  years  of  age.  Chorea  is  comparatively  rare  before  the 
age  of  four.  The  reported  congenital  cases  are  usually  mistaken  in- 
stances of  organic  cerebral  disease.  After  twenty  the  disease  is  most 
rare,  but  may  appear  in  advanced  years.  The  great  majority  of  reported 
senile  cases,  however,  are  instances  of  motor  disturbance  symptomatic 
of  organic  brain  lesions.  It  is  somewhat  more  common  in  unhygienic 
and  cramped  conditions  of  life,  and  hence  in  urban  communities,  but 
spares  no  social  grade  or  locality.  Chorea  is  extremely  rare  in  the 
dark-skinned  races  on  this  continent.  Negroes  and  Indians  of  full 
blood  are  very  seldom  affected.  The  seasonal  relations  of  the  disease 
are  most  interesting.  According  to  Lewis,  the  frequency  of  chorea 
reaches  its  lowest  curve  in  November,  but  rises  rapidly  in  December, 
remains  stationary  in  January  and  February,  mounts  still  higher — to 
its  acme — in  March,  falls  in  April,  again  rises  in  May,  and  then  gradu- 
ally declines  to  its  November  starting-point.      This  trace  corresponds. 

1  Loc.  cit.  2  On  "Chorea,"  Philadelphia,  1894. 


INFECTION  NEUROSES.  531 

with  that  of  rheumatism,  the  general  amount  of  sickness,  and  climatic 
vicissitudes.  The  neurotic  make-ujp  plays  a  distinct  predisposing 
role,  so  that  we  learn  to  expect  a  history  of  various  neuroses  and  psy- 
choses in  the  family,  and  of  "nervousness"  in  the  patient.  Choreics 
commonly  show  some  of  the  so-called  stigmata  of  degeneracy  and  often 
give  a  history  of  pavor  nocturnus,  enuresis,  infantile  convulsions,  febrile 
deliriums,  impressionability,  and  mental  precocity.  It  is  not  rare  to 
find  that  the  mother  has  had  chorea. 

Inciting  Causes. — Fright,  worry,  especially  at  school ;  mental  shock  and 
strain  generally,  and  overstudy  particularly,  are  frequently  alleged  in- 
citing causes,  but  on  close  analysis  usually  retain  but  little  significance. 
Very  frequently  the  early  mental  and  even  motor  symptoms  of  the 
disease  and  of  rheumatism  will  be  found  to  have  antedated  the  psychic 
trauma  that  precipitated  the  choreic  storm.  Imitation  plays  a  most  in- 
significant, if  not  entirely  negative,  role.  A  case  of  true  chorea  in  a 
school  or  home  for  children  may,  however,  start  an  epidemic  of  hys- 
terical St.  Vitus'  dance,  or  of  hysterical  rhythmic  spasms.  Hysteria 
may,  indeed,  ape  chorea  to  the  minutest  detail,  and  they  may  be  associated. 
Traumatism  can  not  be  dissociated  from  mental  shock,  and  parents 
always  assiduously  seek  for  some  such  incident  and  cause.  Its  real 
value  as  an  etiological  factor  is  difficult  to  estimate,  but  seems  slight, 
and  often  the  particular  injury  is  but  one  of  the  insignificant  mishaps 
of  every-day  life  in  childhood.  Reflex  irritation,  prominently  urged  by 
the  older  writers,  arising  from  the  intestines,  and  particularly  from 
worms,  is  seldom  found,  but  should  not  be  overlooked.  Diseased  con- 
ditions in  the  nasopharynx  are  more  likely  to  induce  tics  than  chorea, 
and  the  same  may  be  said  of  eye-strain,  the  fetich  of  some  recent 
writers.  If  the  ocular  apparatus  is  unbalanced  or  refractive  errors  are 
found,  they  should  be  relieved  here  as  well  as  elsewhere.  It  is  not  un- 
reasonable to  suppose  that  their  deleterious  influence  may  protract  the 
nervous  manifestations  of  chorea,  or  may  predispose  to  it  by  lowering 
the  general  tone.  Pregnancy  appears  capable  of  causing  a  recurrence 
of  chorea  or  of  favoring  its  development  and  modifying  its  course.  The 
chorea  of  pregnancy  furnishes  one  of  the  varieties  of  the  disease,  and 
accounts  in  part  for  the  larger  proportion  of  female  cases  in  adult  years. 
As  strongly  urged  by  Tourette,  many  such  cases  are  purely  hysterical, 
though  commonly  considered  choreic.  Chorea  is  sometimes  preceded  or 
accompanied  by  the  infectious  diseases  of  childhood,  as  might  naturally 
be  expected,  given  the  fact  that  chorea  is  especially  a  malady  of  early 
life.  The  relationship  is  mainly  one  of  coincidence.  They  may,  how- 
ever, modify  the  chorea.  Occurring  during  its  early  period,  they  tend 
to  intensify  it,  but  if  it  be  on  the  wane,  they  seem  not  rarely  to  hasten 
its  regression.  The  favorable  influence,  if  it  exists,  may  perhaps  be 
attributed  to  the  forced  rest  they  necessitate,  and  Me  are  to  see  that  rest 
is  the  most  important  element  in  the  treatment  of  chorea.  Anemia  and 
malnutrition  sometimes  precede  chorea,  and  may  furnish  a  certain  liability 
to  its  invasion,  but  usually  they  follow  its  development  and  are  symp- 
tomatic of  it. 

Rheumatism  (Cardiopathy,  Arthritis). — The   questions   arising   re- 


532  NEUEOSES. 

garding  the  relations  existing  between  rheumatism  and  chorea  are 
interesting  and  practically  important.  In  order  to  start  aright,  it  should 
be  stated  that  rheumatism  is  here  meant  to  broadly  signify  the  acute 
manifestations  of  an  infectious  process  that  is  marked  by  inflammatory 
disturbance  of  articular,  serous,  and  endocardial  surfaces.  This  is  pre- 
sumably a  heteropathic  disorder,  but  in  most  instances  due  to  the 
activity  of  an  unknown  specific  micro-organism  ;  unless  we  accept  as 
such  the  streptococcus  isolated  by  Triboulet,  Wasserman,  Pain  and 
Poynton,  and  Benton  and  Walker.  It  has  long  been  observed  that  acute 
rheumatism  and  cardiac  lesions  may  precede,  attend,  or  follow  chorea. 
Diiferent  observers  find  such  relation  in  widely  varying  ratio.  One 
sees  rheumatism  in  "  growing  pains "  ;  another  requires  that  all  the 
articular  manifestations  should  be  present  to  justify  its  recognition. 
The  most  reliable  statistics  give  a  rheumatic  association  in  about 
20  per  cent,  of  all  cases.  Thus,  Osier,  21  per  cent,  and  18.24  per 
cent,  in  two  series;  Townsend,  21;  Crandall,  54;  Starr,  18;  the 
British  Collective  Investigation,  22  per  cent.  Usually  the  arthritis 
precedes  the  chorea,  rarely  it  follows,  and  exceptionally  it  develops 
during  the  progress  of  the  motor  disturbance.  If  the  milder  manifesta- 
tions of  rheumatism  are  accepted  in  this  connection  and  allowances 
made  for  the  unrecognized  cases,  it  is  permissible  to  say  that  it  is 
associated  with  chorea  in  one-half  of  all  cases.  Fatal  cases  of  chorea 
almost  invariably  show  endocardial  vegetations  which  differ  in  no  par- 
ticular from  those  due  to  rheumatic  endocarditis,  yet  such  cases  give  a 
rheumatic  history  in  only  about  twenty-five  per  cent. 

Pathogenesis. — It  is  needless  to  even  enumerate  all  the  theories 
that  have  been  advanced  regarding  the  nature  of  chorea.  Those  now 
advocated  may  be  divided  into  the  neurotic,  the  infectious,  and  the 
rheumatic  theories.  Granting  that  acute  rheumatism  is  an  infectious 
disease,  the  third  division  is  embraced  in  the  second.  The  neurotic 
theory  is  based  largely  upon  the  appearance  of  the  disease  during  the 
years  of  active  growth,  the  common  neurotic  peculiarities  and  antecedents 
of  the  patients,  the  incitement  by  mental  shocks,  the  psychical  symptoms, 
and  the  complexity  of  the  nervous  disorders,  which  embrace  motor,  reflex, 
and  sensory  troubles.  Even  the  arthritis  has  been  referred  to  a  nervous 
source.  Charcot  said  it  was  the  old  question  of  arthritism  in  combina- 
tion with  nervous  diseases.  Joffroy  denominates  chorea  as  a  cerebro- 
spinal neurosis  of  the  period  of  growth. 

The  theory  of  infection  rests  upon  the  influence  of  age,  sex,  and 
season ;  the  association  of  chorea  with  other  infectious,  its  intimate  rela- 
tion with  rheumatism  ;  the  infectious  aspects  of  fatal  cases  clinically,  and 
the  presence  of  endocarditis  at  practically  every  autopsy,  often  accom- 
panied by  pericarditis,  pleurisy,  parotitis,  abscess  formation,  and  other 
septic  processes.  Finally,  there  are  those  who,  following  Kirkes,  Roger, 
and  others,  see  in  chorea  only  a  manifestation  of  rheumatism.  This 
theory  of  identity  is  recently  maintained  by  Churton.  ^  He  says : 
"  The  postulated  toxin  (x)  being  accepted  as  an  essential  element  in 
the  causation  of  rheumatism,  depressing  conditions  (y)  determine  the 
first  position  or  locus  (z)  of  the  disorder.  ...  If  (y)  is  a  fright, 
1  "  British  Med.  Jour.,"  Sept.  19,  1896. 


INFECTION  NEUROSES.  533 

shock,  or  intense  excitement,  (z)  will  be  the  nervous  system  ;  in  the 
developing  brain  of  a  child  the  result  is  usually  chorea  ;  in  adults  it  may 
be  delirium  or  coma,  perhaps  hyperpyrexia.  .  .  .  Wetting  of  the 
feet  always  causes  arthritis  first  in  the  lower  extremities ;  of  shoulders, 
in  the  upper  extremities."  The  embolic  theory  of  Kirkes,  upheld  by 
the  experiments  of  Money,  was  based  on  the  supposition  that  endocar- 
ditis always  preceded  chorea,  which  can  not  be  maintained. 

As  to  the  precise  location  of  the  disease  in  the  nervous  system,  the 
mental  symptoms,  frequent  monoplegic  or  unilateral  distribution  of  the 
chorea,  and  the  practical  exemption  of  the  trophic  functions  of  the  lower 
motor  neuron,  with  absence  of  sensory  disturbance,  point  to  the  cerebral  cor- 
tex. Wood,  from  experiments  and  investigations  in  canine  chorea,  located 
the  disturbance  in  the  spinal  gray,  but  this  disease  is  not  identical  with 
human  chorea. 

Regarding  the  nature  of  the  specific  microbe  in  chorea,  nothing  defi- 
nite can  now  be  offered.  In  1891  Pianese  ^  cultivated  a  rod-shaped 
microbe  from  the  cord  and  brain  of  a  fatal  case  of  chorea,  which,  in- 
jected into  animals,  produced  apathy,  then  tremor,  then  convulsive  move- 
ments, and,  finally,  death.  Autopsical  search  in  these  animals  detected 
this  bacillus  exclusively  in  the  nervous  apparatus.  This  finding  has  not 
been  confirmed.  Dana  ^  has  found  a  diplococcus  in  the  meninges  of  a 
fatal  case,  but  as  subacute  leptomeningitis  was  present,  it  was  possibly 
or  probably  the  specific  micrococcus  of  that  disease.  Various  strepto- 
cocci have  also  been  noted.  Westphal,  Wasserman,  and  Malkoff  ^ 
isolated  from  the  blood,  brain,  and  cardiac  vegetation  of  a  fatal  case  of 
chorea  a  micrococcus  which  produced  arthritis  in  animals. 

Morbid  Anatomy. — As  chorea  is  seldom  fatal,  the  post-mortem 
changes  found  in  the  extraordinarily  severe  cases  that  result  in  death 
can  hardly  be  supposed  to  fairly  represent  the  anatomy  of  the  disease. 
Even  in  such  cases  there  are  no  uniform  or  characteristic  changes.  In 
the  brain  and  spinal  cord  intense  hyperemia,  peri-arterial  exudations, 
minute  hemorrhages,  softened  spots,  and  occasional  emboli  have  been 
noted,  especially  in  the  deeper  portions  of  the  motor  tracts  in  and  about 
the  basal  ganglia.  The  chorea  corpuscle."^,  first  described  by  Elischer, 
and  often  found  by  others,  are  equally  developed  in  various  infections, 
as  proven  by  Manasse,  who  found  them  in  twenty  autopsies  upon  septic 
subjects,  and  was  able  to  produce  them  in  dogs  by  putrescent  intra- 
venous injections.  They  are  hyaline  in  chemical  reaction,  develop  in 
and  around  the  arterioles  and  in  the  perivascular  spaces  throughout  the 
brain  and  cord,  and  furnish  another  argument  for  the  infectious  char- 
acter of  chorea.  Turner  *  describes  swellings  and  opacities  in  the  corti- 
cal pyramidal  cells.  One  of  his  five  cases  had  puerperal  sepsis  and  two 
albuminuria,  both  of  which  might  account  for  the  cellular  changes. 
The  two  remaining  cases,  if  identical,  may  be  taken  as  showing  changes 
of  a  septic  or  infectious  nature.  The  heart  is  more  often  diseased  in  the 
fatal  cases  of  chorea  than  in  any  other  malady  whatsoever.  Osier,  in 
the  73  cases  collected  by  him,  finds  cardiac  lesions  recorded  in  over  90 

1  "La  Riforma  Med.,"  July  14,  1891.       ^  "  Amer.  Jour.  Med.  Sci.,"  Jan.,  1894. 
3  "Berlin,  klin.  Woch.,"  No.  29,  1899.     *  "Path.  Soc.  Trans.,"  1892,  vol.  xlili. 


534  NEUEOSES. 

per  cent.,  consisting  of  recent  endocarditis,  62  cases,  with  pericarditis 
19  times;  pericarditis  alone  in  2  cases;  chronic  mitral  endocarditis 
twice,  and  fatty  heart  once.  The  ordinary  endocardial  appearance  is 
a  row  of  papular  granulations  at  the  mitral  orifice.  All  varieties 
of  incidental  and  accidental  septic  conditions  are  reported  in  the 
literature.  Staphylococcus  aureus  and  pyogenes  have  been  noted  by 
Guizetti,  staphylococcus  aureus  and  streptococcus  by  Reichardt.  Pre- 
oprajensky  ^  claims  to  have  found  streptococci  in  the  blood  in  two 
cases,  both  of  which  were  benefited  by  the  use  of  antistreptococcus 
serum.  Benton  and  Walker  ^  claim  to  have  found  a  specific  streptococ- 
cus in  chorea  and  acute  rheumatism  reacting  in  certain  respects  differ- 
ently from  the  streptococcus  of  human  septicemia. 

Symptoms. — Chorea  is  commonly  of  insidious  onset,  but  its  motor 
symptoms  may  appear  abruptly — that  is,  within  a  few  hours  or  days  after 
a  fright  or  other  mental  disturbance.  In  the  large  majority  of  cases 
parents  can  easily  recall  that  for  a  period  of  days  or  weeks  before  motor 
disturbance  attracted  their  attention  the  child  had  been  peevish,  obsti- 
nate, apprehensive,  easily  displeased,  and  less  companionable  with 
its  playmates.  Perverseness  and  moral  obliquities  sometimes  apjDear. 
Very  commonly  the  sleep  has  been  disturbed  and  broken  by  distressing 
dreams  or  actual  nocturnal  pavor.  More  often  there  is  mere  restless- 
ness and  difficulty  in  getting  to  sleep.  This  prodromic  period  should  be 
-carefully  investigated,  as  it  is  likely  to  give  valuable  warning  in  case  of 
Tecurrent  attacks.  At  school  the  child  becomes  inattentive  and  forget- 
ful, and  finds  increasing  difficulty  with  its  studies.  If  reprimanded, 
there  is  undue  depression  or  unusual  emotion  or  capriciousness.  The 
inability  to  study,  due  to  the  lack  of  mental  concentration,  leads  too 
often  to  the  supposition  of  overstudy ;  but  it  is  particularly  among  the 
bright,  precocious,  and  easily  stimulated  school-children  that  chorea  is 
likely  to  appear.  These  are  exactly  the  children  whose  mental  develop- 
ment should  be  retarded,  and  it  is  among  these  that  forcing  methods 
in  school-work  are  most  baneful. 

After  a  widely  varying  period  the  motor  choreic  features  appear. 
These  at  first  consist  ordinarily  of  sudden,  unwilled,  slight  movements 
or  unexpected  relaxation  of  muscular  contraction.  The  child  appears 
maladroit,  upsets  its  cup,  drops  articles  from  its  hands,  and  lays  itself 
liable  to  admonition,  and,  unfortunately,  in  some  instances,  to  chastise- 
ment, which  may  bring  down  the  choreic  storm  in  a  burst  of  motor 
twitchings,  grimacings,  and  spasmodic  disturbance.  Lacking  cause^  of 
sudden  exacerbation,  the  movements  gradually  become  more  pronounced 
and  bizarre.  There  is  often  complaint  of  fatigue,  pains  in  the  limbs  or 
joints,  and  frequently  loss  of  appetite  and  constipation  are  early  noted. 

Motor  Features. — The  choreic  movements  ordinarily  begin  in  the 
muscles  of  the  hands  and  forearm,  but  the  face  is  soon,  sometimes  first, 
affected,  and  then  the  lower  extremities,  shoulders,  and  trunk,  in  varying 
order.  Occasionally,  the  chorea  is  confined  to  a  single  extremity  or  to 
one  side  of  the  body,  or,  beginning  on  one  side,  may  invade  the  other, 
subsiding  or  persisting  in  the  original  territory.  Commonly,  both  sides 
1  "La  Sem.  M6d.,"  Dec.  10,  1902.  ^  u  g^.   j^^^   Jour.,"  Jan.  31,  1903. 


INFECTION  NEUROSES.  535 

are  not  equally  involved.  As  a  rule,  the  affected  muscles  show  three 
important  functional  modifications:  (1)  Unwilled  but  conscious  twitch- 
ings  or  spasm ;  (2)  inability  to  maintain  steady  contraction,  and  (3)  loss 
of  power.  The  choreic  movements  vary  not  only  in  distribution,  but  in 
intensity  at  different  times  and  in  different  ca,ses.  We  may  first  consider 
a  case  of  average  severity.  The  spontaneous  actions  may  be  described 
as  disordered,  irregular,  arrhythmic,  of  considerable  amplitude,  and  of  a 
rapidity  between  tics  and  athetosis.  They  cease  during  sleep,  though 
there  may  be  great  restlessness.  They  may  even  prevent  sleep.  They 
can  be  slightly  controlled  during  the  execution  of  voluntary  move- 
ments, but  are  excited  and  exaggerated  by  embarrassment  and  any 
emotional  excitement.  Mitchell  and  Rhein  ^  define  several  varieties  of 
choreic  cases  depending  upon  motor  peculiarities  :  "  (1)  Cases  which 
show,  at  some  stage  or  throughout  the  attack,  an  absence  of  movements 
during  rest.  (2)  Cases  with  continuous  movements  during  rest,  but 
increased  by  intentional  effort.  (3)  Cases  with  severe  choreic  move- 
ments, entirely  disappearing  during  muscular  acts.  (4)  Cases  in  which 
the  movements  are  unaltered  by  muscular  efforts.  (5)  Cases  presenting 
several  of  these  phases  at  different  times."  In  the  face  they  usually 
cause  bilateral  grimacing,  especially  affecting  the  lips  and  nose,  less 
frequently  invading  the  muscles  of  the  brow  and  eyelids.  The  lips 
may  be  quickly  pursed  up  or  retracted,  the  tongue  protruded  and  re- 
tracted, the  teeth  snapped  together.  In  this  way  speech  is  impaired  and 
becomes  halting  or  explosive,  due  entirely  to  faults  of  articulation,  as 
the  larynx  is  practically  never  involved.  Swallovnng  is  sometimes 
difficult,  mainly,  however,  on  account  of  the  choreic  movements  of  the 
lips,  cheeks,  tongue,  and  palate.  The  tongue  is  usually  affected  very 
early,  and  in  perhaps  the  majority  of  cases  the  choreic  movements  per- 
sist in  this  organ  after  they  have  elsewhere  disappeared.  Ordinarily, 
if  the  patient  is  asked  to  show  his  tongue  the  chorea  is  at  once  provoked 
in  the  facial  muscles,  but  the  tongue,  too,  is  animated  by  involuntary 
writhings  that  appear,  subside,  reappear,  and  usually  end  in  its  sudden 
retraction  and  the  quick  closing  of  the  mouth.  In  very  exceptional 
cases  the  ocular  muscles  are  implicated,  causing  momentary  diplopia, 
and  movements  in  the  iris  have  been  seen  attending  momentary  con- 
fusion of  vision.  Sluggishness  of  pupillary  contraction  to  light  is  not 
uncommon,  and  a  few  cases  of  retinal  embolism  are  recorded.  ^ 

In  the  upper  extremities  the  choreic  twitching  is  most  and  first  devel- 
oped in  the  fingers,  which  move  individually  or  together,  separate  and 
close,  extend  or  flex,  with  more  or  less  disorder.  Pronation  and  supina- 
tion are  more  common  than  wrist  movements,  and  the  shoulders  are 
more  affected  than  the  elbows.  Indeed,  it  is  rare  that  shrugging  of  one 
or  both  shoulders  does  not  take  place.  When  the  chorea  is  well  marked, 
objects  are  grasped  with  difficulty.  The  hand  approaches  them  by  zig- 
zags and  suddenly  swoops  down  upon  them.  Finally,  prehension  may 
be  impossible,  and  the  patients  can  no  longer  feed  themselves,  or  spill 
everything  they  attempt  to  carry  to  the  mouth.     The  lower  extremities 

1  "Phila.  Med.  Jour.,"  Jan.  22,  1898. 

2  H.  Thomas,  "Johns  Hopkins  Hosp.  Bull.,"  Oct.,  1901. 


536  NEUROSES. 

are  usually  less  affected,  but,  as  in  the  upper  members,  the  digits  show 
the  most  disturbance,  flexing,  extending,  or  separating  in  disorder.  The 
big  toe  and  the  thumb  are  most  active,  as  a  rule.  The  station  is  rendered 
unsteady,  sometimes  uncertain,  and  rarely  impossible,  by  the  movements 
of  the  legs  and  feet.  In  walking  the  gait  is  often  peculiarly  disturbed. 
The  steps  are  unequal  in  length  and  irregular  in  rhythm.  The  feet  may 
be  jerked  from  the  direct  line  of  advance,  raised  too  high,  or  brought 
down  too  vigorously,  but  never  rhythmically.  The  knees  are  not  always 
firmly  supported,  so  that  altogether  there  is  sometimes  presented  a  pecu- 
liar resemblance  to  the  many-jointed  action  of  marionettes  danced  on 
a  string,  which,  taken  with  the  grimaces  and  with  the  contortions  of  the 
hands,  recalls  the  clownishness  Sydenham  so  graphically  described. 
The  muscles  of  the  trunk  and  neck  do  not  escape,  and  may  cause  nod- 
dings  and  bendings  that  are  often  most  apparent  when  the  patient  is 
seated.  The  diaphragm  and  the  thoracic  muscles  are  commonly  invaded, 
causing  irregularity  of  respiration  and  sometimes  spasmodic  noises,  or 
there  may  be  peculiar  involuntary  clucking  or  swallowing  sounds.  The 
choreic  movements  may  be  so  continuous  and  severe  as  to  prevent  sleep, 
to  confine  the  patient  to  bed,  and  to  cause  innumerable  bruises  and  ex- 
coriations by  friction  or  by  rough  contact  with  hard  substances,  such  as 
the  walls  and  furniture. 

If  the  patient  is  directed  to  grasp  the  physician's  hand  and  hold 
firmly,  inequalities  in  pressure  will  at  once  be  observed.  Relaxation  or 
sudden  increase  of  muscular  tension,  or  both,  are  noticed.  Of  still 
greater  importance  is  a  loss  of  muscular  power,  which  is  practically  always 
present  in  muscles  affected  by  chorea,  as  can  be  clearly  shown  in  the 
unilateral  cases.  This  may  reach  a  loss  of  fifty  or  seventy  per  cent.,  and 
in  the  paralytic  form  of  chorea  it  constitutes  the  major  motor  difficulty. 
The  paretic  feature  of  chorea  explains  the  ready  fatigue  and  accentuates 
the  need  of  rest  in  the  management  of  the  disorder.  Riissel  ^  notes 
that  the  handwriting  may  be  (1)  merely  choreic,  (2)  may  be  very  good 
even  when  choreic  disturbance  is  well  marked,  (3)  may  be  almost  im- 
possible though  choreic  movements  are  extremely  slight,  (4)  may  be 
entirely  unintelligible  though  control  of  the  pen  is  good,  and  (5)  may 
present  pure  motor  agraphia. 

The  sphincters  are  never  affected  except  in  the  last  stages  of  the  fatal 
cases.  Objectively,  sensibility  is  normal,  as  a  rule,  and  any  considerable 
anesthesia  or  dysesthesia  should  cause  a  suspicion  of  hysteria.  Triboulet 
laid  much  importance  on  sensitive  spots  beside  the  spinal  processes  of 
the  vertebrae  and  over  the  intercostal  nerves,  but  they  are  inconstant. 
The  electric  excitahility  of  the  nerves  and  muscles  is  sometimes  increased, 
and  the  anodal  closing  contraction  may  equal  the  similar  cathodal  re- 
sponse. General  fo.ss  of  flesh  is  common,  but  localized  muscular  atrophy 
is  very  seldom  found.  Shaw  ^  calls  attention  to  a  jerky  response  upon 
eliciting  the  knee  phenomenon,  otherwise  the  reflexes  are  unaffected. 

Mental  Disturbances. — Aside  from  the  temperamental,  moral,  and 
affective  changes  so  common  in  the  prodromal  stages,  and  which  may  per- 
sist throughout  the  attack,  other  mental  disturbances  may  rarely  occur. 
1  "  Lancet,"  April  1,  1899.  ^  "Albany  Med.  Ann.,"  May,  1897. 


INFECTION  NEUROSES.  537 

The  former  are,  in  a  sense,  proper  to  chorea,  and  with  the  myasthenia 
may  cause  a  marked  change  in  the  fades,  which  presents  an  inane  and 
stupid  appearance,  often  at  great  variance  with  the  normal  attributes  of 
the  child.  Some  of  this  may  be  due  to  the  weakness  of  the  facial  mus- 
cles, but  mainly  it  is  consistent  with  the  hebetude,  irritability,  and 
weakened  mentality  in  such  cases.  Hallucinations  of  sight  are  frequently, 
and  of  the  other  senses  rarely,  noted.  They  usually  appear  toward  or 
during  the  night.  In  the  grave  cases,  when  the  choreic  status  is  produced, 
the  temperature  elevated,  and  the  muscular  activity  at  its  height,  delirium, 
commonly  of  a  hallucinatory  character,  is  often  present.  Occasionally, 
psychoses  of  various  forms  are  encountered — the  concomitant  manifesta- 
tions of  degeneracy. 

Cardiac  Disorders. — In  chorea  the  heart  frequently  presents  clinical 
symptoms,  and  apparently  is  much  oftener  involved  than  auscultation 
indicates.  This  is  shown  by  the  considerable  percentage  of  cardiac 
lesions  in  fatal  cases  without  cardiac  symptoms,  and  the  astonishing 
number  of  cases  of  chorea  which  show  organic  heart-lesions  upon 
examination  years  after  the  chorea  has  disappeared.  During  chorea 
heart-murmurs  are  present  in  about  one-third  of  the  cases,  and  are  func- 
tional or  organic.  In  addition,  tliere  are  disturbances  of  rhythm,  rapid 
action,  and  pain. 

Functional  murmurs  are  most  commonly  heard  at  the  base  and  to  the 
left  of  the  sternum,  with  the  systole  usually  most  intense  over  the  pul- 
monary valves,  and  often  attended  by  rapid  heart-action.  Anemic 
murmurs  over  the  tricuspids  propagated  into  the  neck  are  not  infre- 
quent, and  are  often  associated  with  an  increased  area  of  cardiac 
dullness.  They  may  only  be  noticeable  with  the  patient  in  the  horizontal 
position.  Organic  murmurs  are  usually  the  result  of  endocarditis,  most 
often  affecting  the  mitral  orifice,  systolic  in  point  of  time,  and  with 
greatest  apical  intensity.  Palpitation  and  cardiac  or  precordial  jjain  are, 
on  the  whole,  exceptional.  An  altered  rhythm  is  a  very  common  observa- 
tion in  chorea.  This  has  been  attributed  to  chorea  affecting  the  heart- 
muscle,  but  is  more  reasonably  referable  to  functional  disturbance  and 
respiratory  irregularities,  which  are  very  frequent  in  this  disease.  ^  ery 
often  the  frequency  of  the  heart-beats  is  the  same  in  both  the  horizontal 
and  vertical  positions.  A  rapid  heart  sometimes  persists  after  the  attack. 
Ordinarily,  the  endocarditis  develops  during  the  evolution  of  the  chorea, 
and  is  sometimes  attended  by  joint  symptoms.  Organic  heart  disease 
seems  to  be  most  frequent  from  five  to  ten  years  of  age,  but  this  corre- 
sponds to  the  period  of  the  greatest  frequency  of  chorea.  The  customary 
post-mortem  findings  have  been  already  noted.  Of  equal  or  greater 
importance  are  the  postchoreic  observations.  Thus,  Mackenzie  found 
66.6  per  cent,  of  thirty-one  cases  of  chorea  examined  from  one  to  five 
years  after  the  attack  marked  by  organic  cardiac  lesions.  Osier,  in  a 
more  extended  and  very  closely  scrutinized  series,  found  51-|  per  cent, 
of  postchoreic  cardiopaths.  The  same  thing  is  shown  by  the  long- 
recognized  fact  of  an  increasing  proportion  of  cardiac  diseases  in  the 
subjects  of  repeated  attacks  of  chorea.  The  practical  deduction  points 
the  need  of  systematically  Avatching  the  heart  throughout  the  course  of^ 
and  for  a  long  time  subsequent  to,  the  attack  of  chorea. 


538  NEZTBOSES. 

The  general  state  in  chorea  is  commonly  reduced.  Often,  but 
by  no  means  always,  there  is  some  degree  of  physical  depression  pre- 
vious to  the  onset.  Anemia,  loss  of  appetite,  gastric  indigestion,  slug- 
gishness of  the  bowels,  and  dryness  of  the  skin  are  usually  developed 
early  in  the  choreic  attack,  and  are  sometimes  induced  or  increased  by 
the  injudicious  use  of  arsenic.  Ordinarily,  chorea  is  afebrile.  In  the 
choreic  status  and  in  cases  of  mixed  infection  or  concomitant  sepsis, 
the  temperature  rises  and  is  proportionate  to  its  cause. 

Course. — The  course  of  chorea,  whether  of  insidious  or  of  abrupt 
onset,  is  nsuallv  marked  by  exacerbations  and  remissions  of  the  j)eculiar 
movements.  In  the  majority  of  cases,  after  reaching  various  grades  of 
severity-,  the  chorea  gradually  declines,  leaving  the  lower  extremities,  the 
upper  extremities,  the  trunk,  the  face,  and  the  tongue,  usually  in  the 
order  mentioned.  At  a  time  when  the  movements  no  longer  occur 
spontaneously  they  may  still  be  provoked  in  the  face,  and  especially  in 
the  tongue,  by  directing  it  to  be  vigorously  protruded.  The  average 
duration  of  the  disease  is  from  six:  weeks  to  four  months,  but  cases  lasting 
two  weeks  or  less  and  others  lasting  six  to  eighteen  months  are  not  veiy 
rare.  The  common  termination  of  chorea  is  in  complete  recovery,  though 
death  occurs  in  rare  instances.  A  fatal  termination  results  in  the  very 
severe  cases  in  which  the  choreic  status  exhausts  the  patient,  or  more 
frequently  from  complications,  especially  on  the  part  of  the  heart.  Cere- 
bral hemorrhage  and  softening  and  concurrent  infections  may  lead  to  a 
fatal  termination.  In  other  and  also  very  exceptional  cases  the  chorea 
becomes  chronic.     It  may  also  be  followed  by  a  habit  spasm  or  tic. 

Recurrence  in  chorea  is  so  common  that  it  is  always  to  be  expected, 
and  occurs  in  over  one-third  of  all  cases.  Up  to  the  third  attack  both 
sexes  show  their  usual  relative  susceptibility,  but  beyond  that  number 
the  proportion  of  girls  and  women  rapidly  advances  in  the  lists.  It  is 
rare  to  find  a  male  presenting  more  than  3  attacks,  but  10,  12,  and 
more  attacks  in  females  are  not  very  rare.  Some  patients  present 
chorea  every  spring  for  several  years.  As  a  rule,  succeeding  attacks 
grow  progressively  shorter.  See  gives  the  average  duration  as  139,  80, 
and  55  davs  in  the  first  three  attacks,  respectively.  It  is  to  be  doubted 
that  some  of  the  alleged  repeated  attacks  are  such  in  fact.  In  many 
instances  a  close  examination  of  the  patient  in  the  interval  will  enable 
the  observer  to  evoke  choreic  traces  in  the  face,  tongue,  and  extremi- 
ties, though  parents,  teachers,  and  patients  insist  that  complete  recovery 
has  taken  place.  In  such  instances  a  recurrence,  strictly  speaking,  is 
an  exacerbation.      Choreic  girls  are  also  later  liable  to  gestational  chorea. 

Forms. — Sydenham's  chorea  presents  several  forms  or  modifications 
that  require  individual  mention.  We  may  distinguish  the  common 
form,  which  has  been  the  basis  of  the  above  description  ;  the  grave  form, 
the  gestational  and  the  paralytic  forms. 

The  grave  form,  chorea  gravis,  is  marked  by  an  intensification  of 
all  the  motor  and  usually  of  the  mental  manifestations  of  ordinary 
chorea.  It  is  ordinarily  of  acute  and  intense  onset,  or  may  occur  as  a 
sudden  recurrence  or  intense  exacerbation  of  the  common  type.  The 
choreic  movements  are  wide-spread,  continuous,  and  violent.     They  may 


INFECTION  NEUROSES.  539 

disturb  sleep,  or  prevent  it  altogether.  The  patient  usually  is  unable 
to  stand  or  to  sit  on  a  chair,  and  may  be  so  violently  agitated  as  to  be 
thrown  about  and  off  the  bed.  Swallowing  and  speech  are  interfered 
with  or  rendered  impossible.  Excoriations,  l^ruises,  and  other  injuries 
result.  Infections  may  thus  occur,  inducing  suppurations  and  erysipelas. 
Fever  arises ;  there  is  delirium,  sometimes  of  maniacal  intensity.  Such 
a  continued,  exalted,  intensified,  chorea  has  been  denominated  the  choreic 
status.  The  choreic  state,  thus  constituted,  persists  for  days,  and  finally 
subsides,  death  often  following  coma.  It  differs  only  in  degree  from 
the  milder  attacks,  and  all  gradations  may  be  encountered. 

The  chorea  of  pregnancy,  chorea  gravidarum,  usually  appears  in  young 
primiparse,  commonly  during  the  first  half  of  pregnancy,  and  is  fre- 
quently preceded  by  a  history  of  chorea  in  earlier  life.  The  predisposing 
and  exciting  causes  of  the  common  form  also  obtain  here,  and  the  symp- 
tomatology is  much  the  same.  Cardiac  complications  are  the  rule.  The 
motor  agitation  is  usually  intense,  and  there  is  commonly  involvement 
of  the  pharyngeal  and  respiratory  apparatus,  less  often  of  the  larjmgeal 
mechanism.  Abdominal  and  vaginal  palpation  usually  intensify  the 
choreic  trouble,  and  the  fetal  movements  sometimes  have  the  same  result. 
Mental  disturbance  and  affective  changes  are  nearly  always  present, 
and  tend  to  persist  after  parturition  or  may  only  develop  post  partum. 
Parturition  may  diminish,  augment,  or  fail  to  affect  the  chorea,  but,  on 
the  other  hand,  the  chorea  may  cause  premature  birth  and  abortion. 
Ordinarily,  chorea,  once  established,  persists  until  the  womb  is  evacu- 
ated and  may  continue  during  lactation.  It  is  much  more  serious  than 
the  ordinary  form,  and  terminates  fatally  in  about  twenty  per  cent,  of 
all  cases.     In  some  patients  it  recurs  at  each  subsequent  pregnancy. 

Paralytic  chorea,  called  limp  chorea  by  English  writers,  is  probably 
more  frequent  than  reports  would  indicate.  The  paretic  element  in 
chorea  has  been  particularly  insisted  upon.  In  this  form  it  is  the  dom- 
inant condition,  and  the  choreic  movements  are  insignificant.  It  has 
a  predilection  for  young  children,  and  is  most  frecjuent  at  about  six  or 
seven  years  of  age.  Commonly,  some  infectious  malady  seems  to  act 
as  a  provoking  cause  or  complication.  The  jjremonitory  stage  corre- 
sponds to  that  of  the  ordinary  type.  Ordinarily,  the  paresis  appears  early 
and  may  or  may  not  be  preceded  by  choreic  twitching.  A  mono- 
plegic,  hemiplegic,  or  paraplegic  distribution  may  be  presented,  but 
monoparesis  is  most  common.  The  muscles  are  toneless  and  the  reflexes 
abolished.  There  is,  however,  no  reaction  of  degeneration,  and  the 
outcome  is  usually  complete  recovery  within  a  few  weeks  or  months. 
Muscular  atrophy  sometimes  is  noted.  It  is  not  unlikely  that  some 
cases  brought  under  this  head  really  belong  to  the  neuritides,  or  to 
myelitis,  or  are  combinations  of  these  with  chorea. 

Diagnosis. — The  diagnosis  of  chorea  is  extremely  simple  when  the 
motor  symptoms  are  once  developed.  Difficulty  arises  usually  through 
mistaking  symptomatic  choreoid  movements  in  other  diseases  for  true 
chorea.  The  escort  of  attending  symptoms  should  differentiate  these 
pseudochoreas.  Here  may  be  mentioned  the  rhythmic  tremblings  of 
metallic    and   toxic   poisoning,   of  hysteria,   and   of  multiple    sclerosis. 


540  NEUROSES. 

Friedreich's  ataxia,  athetosis,  and  posthemiplegic  chorea  have  their  cerebral 
signs.  Tics  are  more  sudden  and  more  completely  expressional  or 
gesticulatory  in  character,  showing  their  subconscious,  purposive  basis. 
Huntingdon's  chorea  almost  invariably  has  a  familial  history,  comes  on 
after  adult  years,  and  is  attended  by  progressive  dementia.  The 
myoclonias  and  the  so-called  electrical  choreas  present  only  a  superficial 
resemblance  to  the  chorea  of  Sydenham.  The  premonitory  symptoms 
for  a  given  case  having  been  made  out,  their  reappearance  often  enables 
the  early  diagnosis  of  recurrent  attacks  before  motor  symptoms  attain 
prominence. 

Prognosis. — In  the  great  majority  of  cases  chorea  may  be  con- 
sidered a  self-limited  disease  of  favorable  prognosis.  Complete  recovery 
is  the  rule  in  children  under  ten  years  of  age.  In  proportion  as  puberty 
is  reached  and  adult  years  attained,  the  prognosis  becomes  more  guarded 
both  as  to  immediate  results  and  the  establishment  of  chronicity.  Recur- 
rent attacks,  however,  have  a  progressive  tendency  to  earlier  recovery. 
In  a  given  case  the  intensity  of  the  attack,  the  violence  of  the  choreic 
motions,  their  generalization,  the  evidence  of  degeneracy  in  the  indi- 
vidual, and  a  bad  general  physical  state  unfavorably  modify  the  outlook 
for  early  recovery.  The  prognosis  is  also  aifected  by  the  presence  or 
development  of  cardiac  involvement  or  the  appearance  of  septic  pro- 
cesses and  high  temperatures.  The  choreic  status  is  of  xery  grave 
significance,  and  usually  terminates  in  death.  Chorea  in  pregnancy  also 
furnishes  a  high  mortality  for  the  mother  and  more  often  destroys  the 
fetus. 

Treatment. — In  the  treatment  of  chorea  the  constant  evidence  of 
muscular  weakness  and  mental  enfeeblement  calls  in  decided  tones  for 
rest.  Any  emotional  disturbance  promptly  aggravates  the  choreic 
movements.  The  child  in  ordinary  cases  must  be  taken  from  school 
and  kept  apart  from  the  romps  and  often  from  the  gibes  of  its  play- 
mates, and  for  the  most  part  in  bed.  A  little  chloral  to  induce  sleep, 
and  frequent  sponge-baths,  gentle  massage,  and  pleasant,  quiet  diversion 
will  often,  with  rest,  work  great  improvement  in  a  few  days.  Tonics, 
especially  iron,  are  usually  indicated,  and  attention  to  the  constipation  is 
always  in  order.  The  diet  should  be  nutritious  and  easily  assimilated, 
and  contain  plenty  of  fat  in  the  form  of  cream  and  butter.  It  should 
be  carefully  controlled,  as  choreics  are  very  prone  to  crave  indigestible 
and  objectionable  articles.  The  use  of  drugs  is  of  secondary  importance. 
Arsenic,  once  in  vogue,  is  valuable  as  a  tonic  in  small  doses,  but  usually 
harmful  in  large  ones  and  only  rarely  efficacious  against  the  chorea 
when  pushed  to  the  utmost  limit  of  toleration.  It  is  capable  of  pro- 
ducing all  sorts  of  intestinal  disturbance,  and  its  protracted  use  may 
induce  pigmentary  changes  in  the  skin  or  cause  a  multiple  peripheral 
neuritis.  It  must,  however,  be  admitted  that  in  some  cases  a  short, 
vigorous  course  of  arsenic  reaching  ten  to  fifteen  drops  of  Fowler's 
solution,  three  times  daily,  for  a  child  six  or  seven  years  old,  sometimes 
acts  favorably.  It  may  be  commenced  with  a  single  drop  and  increased 
one  drop  a  dose  until  the  stomach  rebels,  which  is  usually  at  about  twelve 
drops.      It  should  then  be  stopped  for  a  day  and  renewed  at  the  final 


INFECTION  NEUROSES.  541 

dose  and  slowly  increased.  It  can  rarely  be  used  more  than  three 
weeks  at  a  time  with  advantage.  The  use  of  quinin  in  large  doses,  as 
suggested  by  Wood,  has  in  a  series  of  cases  in  the  writer's  clinic  failed 
to  prove  of  any  value. 

In  the  severe  oases  absolute  quiet  and  rest  in  bed  or  in  a  padded 
corner  on  the  floor  is  required.  Food  must  sometimes  be  given  by  the 
nasal  or  rectal  tube  and  chloral  must  be  used  freely,  associated  with 
bromid  if  there  is  much  delirium.  Even  morphin  may  be  required, 
and  strychnin  to  maintain  the  heart.  Sulphonal,  trional,  exalgin,  and 
antipyrin  have  given  help  in  some  such  cases.  Hot  baths  and  cold  packs 
often  are  of  distinct  service.  The  conservation  of  strength  and  the 
support  of  the  physical  forces  require  most  careful  thought. 

In  the  chorea  of  pregnancy  it  is  seldom  needful  to  terminate  gestation, 
but  if  the  motor  storm  is  very  violent  and  the  mental  features  pro- 
nounced, or  the  physical  state  low,  it  may  be  indicated,  especially  as 
amelioration  sometimes  follows  spontaneous  abortion  or  delivery  at 
term. 

Complications  such  as  phlegmons,  joint  disease,  and  cardiac  involve- 
ment must  be  met  on  their  indications.  Recurrences  should  be  anticipated 
and  the  parents  should  be  taught  the  significance  of  sleeplessness,  irri- 
tability, fidgetiness,  capriciousness  of  conduct  and  appetite,  and  at  once 
resume  proper  treatment.  In  girls  this  is  particularly  needed.  In  the 
pubescent  period  and  later  gestational  experience,  watchfulness  should 
be  exercised  to  maintain  both  the  general  health  and  the  body-weight 
at  a  proper  level. 


542  NEUBOSES. 


CHAPTER  III. 
MOTOR  NEUROSES. 

The  neuroses  brought  under  the  above  heading  have,  in  common,  a 
preponderance  of  motor  symptoms.  Their  grouping  is  entirely  arbi- 
trary and  one  of  convenience. 


HUNTINGDON'S  DISEASE. 

In  1872  Huntingdon  called  marked  attention  to  a  number  of  families 
living  in  southeastern  New  York,  who  had  for  many  years  been  under 
the  continuous  observation  of  his  father  and  grandfather,  both  medical 
men.  These  people  were  afflicted  with  a  family  disease  locally  known  as 
"  megrims  "  or  "  megrums,"  and  owing  to  their  peculiar  motor  difficul- 
ties, the  patients  were  commonly  called  "  shakers."  The  disease  has 
been  recognized  in  many  parts  of  the  world,  and  is  variously  denomi- 
nated Huntingdon's  chorea,  chorea  of  the  aged,  family  chorea,  aduU  heredi- 
tary chorea,  chronic  chorea,  and  chronic  progressive  chorea.  As  it  has  no 
well-founded  relation  to  Sydenham's  chorea,  the  term  Huntingdon' s  dis- 
ease is  here  adopted  as  open  to  the  least  objection.  The  disorder  pre- 
sents an  insidious  onset  in  adult  life,  a  marked  hereditary  character,  and 
a  well-defined  tendency  to  mental  deterioration  and  dementia. 

Etiology. — The  salient  etiological  feature  of  Huntingdon's  disease 
is  its  heredity.  It  has  been  traced  through  five  generations,  and  in  a 
given  family  marks  more  victims  than  any  other  familial  disorder, 
sometimes  affecting  as  many  as  half  of  the  entire  number.  It  is  trans- 
mitted about  equally  by  males  and  females,  but  presents  the  peculiarity 
of  never  reappearing  after  once  the  hereditary  chain  is  broken.  Thus 
it  never  skips  a  generation.  In  contrast  to  true  chorea  it  affects  the 
male  sex  in  greater  proportion.  Huet  collected  a  series  of  cases  em- 
bracing forty-four  men  and  thirty-six  women.  It  is  also  at  variance 
with  chorea  in  the  factor  of  age.  It  usually  appears  from  thirty  to 
forty-five,  but  may  develop  at  any  later  period.  Exceptionally,  it  has 
been  noted  at  puberty,  never  in  childhood  or  infancy.  Again,  rheuma- 
tism in  the  personal  and  family  antecedents  is  rare.  In  some  instances 
fright  or  other  mental  trauma  has  appeared  to  induce  it.  Epilepsy  is 
sometimes  associated  with  it. 

Morbid  Anatomy. — It  may  be  stated  that  no  characteristic  changes 
are  recorded  in  the  cases  examined  post  mortem.  They  are  those  common 
to  dementia  in  general.  Thus  Lannois  and  Paviot  ^  in  two  cases  found 
meningeal  thickening,  pachymeningitis,  cerebral  atrophy  and  compensa- 
tory hydrocephalus.  The  descending  cord-tracts  and  the  anterolateral 
and  cerebellar  tracts  were  slightly  sclerotic.  The  cortical  layers  pre- 
1  "Arch,  de  Neurol.,"  Oct.,  1897. 


MOTOR  NEUROSES.  543 

sented  a  round-cell  infiltmtion.  C.  A.  Good  ^  and  Kattwinkel  have 
found  in  well-examined  cases  no  evidence  of  inflammation,  but  wide- 
spread degenerative  cellular  changes  throughout  the  cortex,  most 
marked,  however,  in  the  frontal  regions. 

Symptoms. — The  motor  symptoms  commonly  appear  insidiously, 
but  in  some  cases  mental  enfeeblement  precedes.  The  face,  the  speech, 
or  the  gait  may  be  first  involved.  Slow  involuntary  contractions 
modify  the  facial  expression,  cause  a  hand  to  start,  a  finger  to  move,  or 
compel  the  feet  to  deviate  from  the  intended  direction.  These  motions 
at  first  are  temporarily  controllable,  or  cease  on  brief  voluntary  effort. 
Later,  they  are  not  under  such  control.  The  gait  becomes  progressively 
more  erratic  and  uncertain,  until,  finally,  it  closely  resembles  that  of 
drunkenness  with  the  addition  of  gesticulatory  movements  of  the  arms 
and  of  facial  contortions.  The  peculiar  gestures,  poses,  and  exaggera- 
tions of  action  in  these  cases  are  very  prominent  and  often  strangely 
at  variance  with  the  mental  emotions  actually  in  play.  They  are 
increased  by  embarrassment  and  emotion,  but  lessen  in  repose  and  sub- 
side during  sleep.  Though  bearing  a  rough  resemblance  to  the  move- 
ments of  chorea,  they  are  more  deliberate,  gesticulatory,  and  of  greater 
range.  There  is  usually  some  muscular  weakness,  but  no  other  modifi- 
cation of  energy  and  none  of  sensation.  Speech  is  thickened,  drawling, 
and  infiltrated  with  ha's  and  hem's,  but  not  staccato  or  explosive,  and 
may  finally  become  impossible.  In  advanced  cases  the  patient  may  be- 
come bedridden. 

The  mental  state  is  one  of  progressive  enfeeblement  and  depression. 
It  is  of  slow  onset  and  its  natural  goal  is  complete  dementia.  It  may 
precede  the  motor  symptoms,  but  usually  follows  them  at  a  varying 
period.  Thereafter  the  muscular  and  mental  disability  increase  together 
to  the  end  of  life.  A  duration  of  ten  to  thirty  years  is  common  and  old 
age  is  often  attained.     Recoveries  are  unknown. 

Diagnosis. — Huntingdon's  disease  encountered  in  a  nmnber  of 
generations  can  offer  no  diagnostic  difficulty.  Originating  de  novo,  it 
must  be  distinguished  from  chorea  proper,  from  the  maladie  des  tics, 
from  double  athetosis,  and  from  the  family  ataxias.  Chorea  has  its 
early  mental  symptoms,  its  cardiac  lesions,  its  tendency  to  recover,  and 
an  absence  of  extreme  mental  degradation.  Tics  have  a  limited  distri- 
bution,  are  much  quicker  in  their  rhythm  or  activity,  and  present  no 
dementia  unless  occurring  in  idiocy.  Athetosis  is  congenital,  infantile, 
or  postparalytic  in  development.  The  family  ataxias  have  their  eye 
symptoms,  lack  mental  degeneracy,  and  commonly  appear  early  in  life. 

Treatment  has  been  futile. 


MYOCLONIA. 

The  term  myoclonus  or  paramyoclonus  has  been  used  to  designate  in- 
voluntary, unsystematized,  arrhythmic,  quick,  muscular  contractions, 
similar  to  those  produced  by  an  electric  shock.  They  may  be  localized  or 
disseminated  and  may  embrace  a  muscle,  a  muscle  group,  or  only  a  few 
muscular  fibers.  Under  the  general  term  myoclonia  may  be  embraced 
1  "Amer.  Jour,  of  Insanity,"  July,  1900. 


544  NEUROSES. 

the  paramyoclonus  multiplex  of  Friedreich,  the  electric  chorea  of  Bergeron, 
Henoch,  Paget,  and  the  fibrillary  chorea  of  Morvan.  Senile  chorea,  so 
called,  is  generally  but  the  motor  index  of  cortical  degenerative  changes. 
Myoclonia  is  sometimes  combined  with  epilepsy,  furnishing  the  "  asso- 
ciation disease "  of  myoclonus-epilepsy,  to  be  described  with  epilepsy. 

Etiology. — Practically  nothing  is  kno^v^l  of  the  causation  of  myo- 
clonia. Lundborg  ^  has  suggested  that  it  bears  some  relation  to  the 
thyroid.  Nervous  heredity  is  commonly  encountered,  the  male  sex  pre- 
ponderates, and  adult  age  is  the  usual  epoch,  though  Bergeron's  form  is 
most  common  in  children.  Overwork,  fatigue,  hunger,  fear,  traumatism, 
and  cold  have  been  considered  excitants. 

The  nature  of  the  disease  is  speculative,  but  the  motor  cells  in  cortex 
and  cord  are  presumed  to  be  at  fault.  A  case  in  which  muscular 
atrophy  followed  is  thought  to  add  force  to  this  point  of  view  so  far  as 
it  relates  to  the  cord.  The  morbid  anatomy  is  practically  unknown. 
Murri  2  found  a  chronic  localized  pachymeningitis  with  atrophy  of  the 
central  cortex  in  one  case. 

Symptoms. — The  onset  may  be  sudden,  following  one  of  the  in- 
citing causes  mentioned,  or  the  motor  symptoms  may  insidiously  develop. 
These  are  the  essential  features  of  the  disease,  which  lacks  sensory, 
trophic,  dynamic,  and  electrical  symptoms  but  usually  presents  increased 
tendon  reflexes.  The  clonic  contractions  begin  ordinarily  in  the  lower 
extremities,  and,  as  a  rule,  are  bilateral,  though  not  strictly  symmetrical. 
They  then  invoh^e  the  upper  limbs,  but  commonly  spare  the  face.  The 
clonic  contractions  are  instantaneous  and  involuntary,  increased  by 
emotion,  but  subject  to  some  degree  of  voluntary  control.  They  subside 
or  remain  in  abeyance  during  voluntary  use  of  the  given  muscles,  at 
least  for  a  few  minutes.  Depending  upon  their  location,  extent,  and 
intensity,  they  may  appear  only  as  a  contracting  muscular  bundle,  pro- 
ducing a  linear  elevation  of  the  skin,  or  may  cause  a  joint,  a  digit,  or 
an  entire  extremity  to  start  suddenly.  Usually  clonic,  they  may  be 
repeated  so  rapidly  as  to  produce  a  tonic,  or  even  tetanic  effect.  One 
or  all  varieties  may  be  observed  in  the  same  patient.  The  contractions 
are  unequal,  irregular,  and  arrhythmic.  Sometimes  they  produce  con- 
stant agitation  ;  sometimes  they  come  on  in  little  attacks,  with  varying 
intervals  of  quiet.  They  may  reach  a  rate  of  60  to  100  a  minute,  and, 
as  a  rule,  are  more  rapid  the  smaller  the  muscle  affected.  They  cease 
during  sleep,  but  in  some  instances  may  rouse  the  patient  in  the  night. 
Percussion,  pinching,  heat  or  cold,  electric  shocks,  and  the  emotions  tend 
to  augment  and  recall  them.  The  intellect  is  unaffected.  The  face, 
tongue,  and  trunk  are  exceptionally  involved.  The  muscles  of  organic 
life  and  the  sphincters  escape. 

When  the  disease  begins  insidiously,  the  contractions  come  on  during 
repose  and  at  long  intervals,  attracting  little  attention.  They  progress- 
ively increase  in  extent  and  vigor,  and  in  a  few  weeks  or  months  reach 
the  period  of  complete  development,  which  varies  in  duration  in  different 
cases,  but  is  usually  protracted  many  months.  The  tendency  of  the  dis- 
ease is  then  to  subside  slowly  toward  complete  recovery,  but  often  with 
remissions  or  later  recurrence.     Most  cases  finally  recover. 

1  "Hygeia,"  1900.  ^  "Arch.  Ital.  di  Biol.,"  1901. 


MOTOR  NEUROSES.  545 

Diagnosis. — The  diagnosis,  owing  to  the  rarity  of  the  affection,  is 
seldom  made.  Tics  are  likely  to  be  mistaken  for  myoclonia  unless  the 
case  is  carefully  studied.  These,  however,  are  almost  invariably  first 
unilateral,  and  have  a  predilection  for  the  face,  whence  they  usually 
spread  to  the  neck,  arms,  etc.  They  are  distinctly  purposive  in  char- 
acter, and  expressive  or  gesticulatory,  demonstrating  the  subconscious 
basis  on  which  they  develop.  Jacksonian^fe  are  usually  attended  by 
sensory  aurae,  mental  disturbance,  and  major  convulsions  at  some  period 
of  the  disorder. 

The  prognosis  is  good. 

Treatment  has  appeared  to  have  little  effect.  The  use  of  galvan- 
ism to  spine  and  muscles  is  favored  by  some,  and  motor  inhibitors,  such 
as  atropin,  eserin,  valerian,  hyoscin,  and  cocain,  have  been  employed 
with  varying  results.  Commonly,  the  general  physical  condition  requires 
appropriate  attention. 


DUBININS  DISEASE. 

In  1845  Dubini  described  a  disease  occurring  in  the  malarial 
regions  of  Italy  which  he  called  electrical  chorea.  The  name  is  unfor- 
tunate, as  the  condition  is  not  allied  to  Sydenham's  chorea,  nor  does  it 
resemble  it  in  any  manner.  This  name  has  also  been  applied  to  several 
varieties  of  myclonus,  and  to  some  hysterical  manifestations,  with  equal 
disadvantage.  The  morhkl  anatomy  is  not  yet  determined,  though  many 
of  these  cases  have  been  examined  post  mortem.  In  nearly  all  there  is 
evidence  of  infection,  such  as  pulmonary  and  splenic  congestion,  inflam- 
mation of  the  meninges,  increase  of  cerebrospinal  fluid,  cerebral  con- 
gestion, especially  at  the  base,  and  softened  foci  in  the  cortex  and 
great  ganglia.  In  some  earlier  instances  the  cerebrospinal  axis  w^as  re- 
ported of  normal  appearance.  This  statement  may  be  received  with 
some  doubt.  The  disease  has  been  attributed  to  everything,  from 
malaria  to  typhus,  and  seems  to  be  confined  to  Italy,  and  especially  to 
L'ombardy. 

The  onset  is  abrupt  and  marked  by  intense,  continuous  pains  in  the 
head,  neck,  and  sometimes  in  the  lumbar  region.  Shortly  the  extremi- 
ties are  seized  with  short,  sharp  spasms,  recalling  the  electrical 
responses,  and  giving  rise  to  the  name  "  electrical  chorea."  They  usu- 
ally first  appear  in  the  upper  extremities,  especially  in  the  hands  and 
fingers,  sometimes  in  the  face,  and  are  attended  by  painful  sensations  in 
the  same  locality.  Gradually  they  spread  into  a  hemiplegic  or  diplegic 
distribution,  which  is  attained  within  a  week  or  two.  The  twitchings 
occur  at  somewhat  regular  intervals,  and  frequently  are  accompanied  by 
epileptoid  convulsions,  without  loss  of  consciousness,  which  may  take 
place  several  times  in  the  twenty-four  hours,  and  commonly  leave 
paretic  traces  behind  them.  Sensibility  is  not  greatly  affected,  though 
sometimes  hypersensitiveness  may  be  easily  ])rovoked  and  exalts  the 
motor  symptoms.     Electrical  reactions  are  said  to  be  normal. 

The  disease  usually  grows  progressively  worse.  The  muscular  spasms 
become  almost  continuous,  the  convulsions  are  rapidly  repeated,  and  in 
35 


546  NEUROSES. 

from  ten  to  one  hundred  and  fifty  days  the  disease  ends  in  death  in 
about  ninety  per  cent,  of  all  cases.  The  fatal  termination  is  preceded 
by  a  condition  of  continuous  epileptoid  spasm,  a  sort  of  status,  followed 
by  coma,  relaxation,  and  fatal  exhaustion.  Occasionally,  there  are  re- 
missions in  the  progress  of  the  disease.    Treatment  has  been  unavailing. 

PARKINSON'S  DISEASE,  PARALYSIS  AGITANS. 

In  1817  Parkinson  gave  a  complete  clinical  description  of  a  rather 
common  disease,  which  he  termed  shaking  palsy.  It  is  generally  known 
as  paralysis  agitans.  As  the  usual  weakness  may  be  absent  and  the 
tremor  may  appear  only  late  in  the  disease,  the  descriptive  name  is  not 
always  apj)licable.  Generally,  it  is  considered  a  neurosis,  but  accumu- 
lating material  points  to  an  organic  basis  for  the  malady,  wdiich  wall 
probably  soon  pass  into  its  proper  category.  The  disease  is  one  of  late 
middle  life,  usually  commencing  locally,  tending  to  hemiplegic  and 
fi^nally  to  diplegic  distribution,  and  commonly  marked  by  rigidity, 
tremor,  and  w^eakness  of  similar  extent.  Never  fatal  in  itself,  it  lasts 
until  death. 

Etiology. — Parkinson's  disease  rarely  commences  before  forty  or 
after  sixty-five  years  of  age.  Most  commonly  it  appears  at  about  fifty. 
The  male  sex  furnishes  over  two-thirds  of  all  cases,  and  this  proportion  is 
uniform  for  all  ages.  A  neuropathic  heredity  is  commonly  encountered. 
In  exceptional  instances  the  disease  appears  in  several  generations  or  in 
collateral  family  branches.  Lundborg  ^  has  recorded  five  cases  in  one 
family,  several  other  members  being  affected  wdth  myoclonia,  both  of 
which  diseases  he  thinks  related  to  disorders  of  thyroidal  action.  In 
another  case  he  saw  Parkinson's  disease  with  myxedema.  Fraenkel  ^ 
has  also  called  attention  to  myxedematous  areas  in  paralysis  agitans 
which  are  suggestive  of  a  glandular  factor.  Among  the  alleged  exciting 
causes,  fear,  anxiety,  grief,  and  physical  exhaustion  have  been  named. 
In  Paris  and  Strasburg  during  the  sieges  of  the  Franco-Prussian  War 
and  in  the  American  Pebellion  numerous  cases  developed  under  the 
combined  influences  of  privation,  prolonged  anxiety,  and  sudden  fears. 
Traumatism  has  appeared  to  incite  it,  and  in  such  instances  the  tremor 
has  sometimes  appeared  in  the  limb  affected,  sometimes  even  in  the  part 
of  the  limb  directly  injured.  KrafPt-Ebing  ^  traced  the  disorder  to 
trauma  in  7  out  of  110  cases.  The  possibility  of  hysteria  in  such  cases 
is  strong.     Mental  shock  can  not  be  excluded  in  such  accidents. 

Morbid  Anatomy. — Regarding  the  morbid  anatomy  of  Parkinson's 
disease  there  is  much  diversity  of  opinion  and  observation.  In  typical 
cases  Westphal,  Berger,  Charcot,  and  Gowers  have  found  no  abnor- 
malities. Others  have  found  changes  in  the  encephalon,  cord,  and  even 
in  the  muscles.  Dubief  and  Ketscher  have  noted  retrograde  changes 
in  the  motor  cells  of  the  anterior  horns  and  sclerous  changes  in  the 
M'hite  tracts  of  the  cord,  recalling  those  due  to  senility.  Redlich  *  in 
seven  cases  found  the  cord  most  affected.  Small  patches  of  sclerosis 
were  found,  mainly  in  the  posterior  columns,  but  some  in  the  lateral 

1  "Hvgeia,"  1900.  ^  "  Deut.  Zeit.  f.  Nervenh.,"  April,  1899. 

»  "Wien.  klin.  Woch.,"  1899.  *  "  Centralbl.  f.  allge.  Path.,"  Nov.  4,  1894. 


MOTOR  NEUROSES. 


547 


tracts,  and  most  frequently  at  the  level  of  the  cervical  and  lumbar 
enlargements.  They  originated  from  the  vessels,  and  showed  atrophy 
of  nerve-fibers  and  increase  in  interstitial  tissue.  The  process  was  an 
endo-  or  peri-arteritis,  with  extension  to  the  surrounding  parts.  The 
cells  of  the  anterior  gray  and  Clarke's  columns  were  almost  always 
pigmented.  He  recognized  the  changes  as  senile  in  part,  but  thinks 
they  exceed  it  in  degree.  Dana  has  described  a  diifuse  sclerous  myelitis 
with  vascular  lesions  and  cellular  atrophy  in  both  cord  and  cortex. 
Mendel,  Charcot,  Bloch,  and  Marinesco  in  three  cases  have  found 
tubercles  in  the  peduncular  region,  and  Brissaud,  from  a  study  of 
pseudobulbar  palsies  in  connection  with  paralysis  agitans,  is  inclined  to 
locate  the  lesion  in  the  peduncular  territory.  The  monoplegic  and 
hemiplegic  cases  indicate  cerebral  disorder  and  the  involvement  of  the 
face-  and  jaw-muscles  is  certainly  due  to  supracordal 
states.  Gordinier  ^  has  collated  24  cases  examined 
by  recent  methods.  In  all  there  was  decided  uni- 
formity of  anatomical  findings.  These  involved 
blood-vessels,  neuroglia,  and  nerve-cells.  There  was 
proliferation  of  nuclei  and  thickening  of  vascular 
walls,  increase  of  neuroglia  about  the  blood-vessels, 
and  patches  of  perivascular  sclerosis,  with  pigmen- 
tation, degeneration,  and  atrophy  of  nerve-cells  and 
nerve-fibers.  The  spinal  cord  was  most  affected, 
the  changes  being  most  marked  in  the  gray  matter 
and  posterolateral  portions  of  the  lumbar  and  cer- 
vical enlargements,  usually  decreasing  brainward, 
and  sometimes  not  appearing  in  the  encephalon. 
Though  resembling  senile  changes,  the  lesions  were 
more  intense  and  general  arteriosclerosis  was  usu- 
ally absent.  At  present  we  can  go  no  further  than 
the  supposition  that  vascular  faults  are  primary,  the 
neuroglia  and  cellular  structures  being  secondarily 
involved  in  degenerative  changes.  Fatty  changes  in 
the  muscles  are  encountered  in  very  old  cases,  and 
sometimes  a  peripheral  nerve  degeneration  of  a 
slight  degree. 

Symptoms. — A  typical  case  of  Parkinson's  disease  presents  a  most 
striking  picture.  The  patient  trots  into  the  room  with  short,  reluctant 
steps,  apparently  following  his  center  of  gravity.  The  body  is  inclined 
forward,  the  neck  extended  and  rigid,  the  elbows  flexed  and  slightly 
abducted,  bringing  the  hands,  with  their  trembling  fingers,  to  the  level 
of  the  groins.  The  face  is  mask-like,  the  eyes  bright  and  unwinking. 
The  patient  turns  bodily,  deliberately,  and  rigidly.  He  sits  down 
slowly,  with  precaution,  on  the  edge  of  the  chair,  always  leaning  for- 
ward, his  shaking  hands  on  his  knees  in  constant  motion.  Every  change 
of  position  is  studied  and  reluctant.  We  may  take  up  the  symptoms 
in  detail. 

The  muscular  rigidity  is  worthy  of  first   attention,   as   it  is  the 
^  "Amer.  Jour.  Med.  Sciences,"  Dec,  1899. 


Fig.    234. — Parkinson's 
disease.    Attitude. 


548 


NEUROSES. 


dominant  motor  phenomenon,  causing  the  peculiar  attitudes  and  pos- 
tures, the  immobile  face,  and  the  slowness  of  movement.  It  is  the  motor 
analogue  of  the  mental  inertia  so  common  in  this  disease.  It  is  nearly 
always  present  where  the  tremor  exists,  and  may  be  highly  developed 
without  the  tremor,  or  may  first  invade  the  parts  that  subsequently 


P^ig.  235. — Sitting  attitude  in  paralysis 
agitans. 


Fig.  2.36. — Parkinson's  disease  :  facias. 


tremble.  Owing  to  the  rigidity,  this  reaction-time  is  increased  about 
forty  per  cent.  Passive  motion  is  sometimes  impeded  by  the  rigidity, 
but  there  is  no  hypertonus  and  the  tendon  reflexes  are  only  slightly  in- 
creased. A  foot-clonus  is  never  encountered.  There  is  a  characteristic 
fades.     The  nasolabial  folds  and  lines  of  expression  tend  to  disappear. 

The  face  becomes  smooth.    The  brow  may 
.^^-  retain  its  cross-wrinkles  through  enforced 

t^^^HIHIIIl  elevation  requisite  for  forward  vision,  if 

^...^^flBKBfck.  the  body  and  head  be  bowed.     The  eyes 

are  widely  opened  and  rarely  wink.     The 
ocular  globes  tend  to  remain  fixed  so  that 
the  patient,  in  order  to  change  the  direction 
of  vision,  ordinarily  turns  bodily  with  the 
neck  held  rigid.     Movements  of   ocular 
association   and    accommodation    are  im- 
peded   by  this    rigidity,  and  the  patient 
shows  little  or  no  facial  variation  for  gjiy 
of  the  emotions  that  may  play  behind  this 
mask.     Speech  is  modified.      It  becomes 
monotonous  and  deliberate.     The  patient 
hesitates,  but,  once  started,  hurries  his  sentences  and  stops  abruptly  as 
if  relieved  to  be  through.    He  likes  monosyllables  and  may  become  ex- 
tremely taciturn. 

In  the  'aeclc  all  the  muscles  are  involved,  giving  an  appearance  of 
stiflF-neck  or  rheumatic  torticollis,  but  the  face  is  ahVays  held  to  the 
middle  line,  the  chin  commonly  somewhat  advanced.  The  body  is  bent 
forward  throughout  its  length  and  also  at  the  hips.     There  is  every- 


Fig  237. — Gait  in  paralysis  agitans, 
showing  propulsion. 


MOTOR  NEUROSES.  549 

where  a  preponderance  of  flexor  positions,  as  a  rule,  but  in  very  excep- 
tional cases  the  neck  and  body  may  be  bent  backward.  The  arms, 
naturally  drooping  forward,  are  flexed  at  the  elbows,  which  are  slightly 
separated  from  the  sides.  The  hands  may  be  partly  flexed  or  ex- 
tended at  the  wrist,  but  the  fingers  are  always  held  more  or  less  in 
flexion.  A  position  similar  to  that  of  holding  a  pen  is  common,  or  the 
hand  may  be  partially  closed.  The  digits  frequently  deviate  to  the 
ulnar  side  of  the  hand,  as  in  rheumatoid  conditions,  and  these  may  also 
be  present.  In  the  lower  extremity  the  stiiFness  is  less  marked,  but  in 
advanced  cases  causes  a  knee-sprung  attitude  and  gait. 

The  gait  of  Parkinsonians  is  strikingly  peculiar.  When  the  patient 
rises  from  the  chair,  he  hesitates  a  moment  as  if  to  take  aim,  and  starts 
ahead  in  a  direct  line,  his  laggard  legs  trotting  to  keep  up  with  the  for- 
ward-leaning body.  In  some  instances  the  patient  is  strongly  impelled 
forward,  and  can  only  arrest  himself  by  running  into  objects  or  passers-by. 
There  may  or  may  not  be  an  actual  tendency  to  fall  forward,  or  propul- 
sion, but  in  some  cases,  if  the  body  be  started  backward,  sideways,  or 
forward  by  a  push,  the  direction  is  maintained  for  a  few  or  many  steps, 


Jl/"  4^4  -flMOACU^. 


Fig.  238.— Handwriting  in  Parkinson's  disease,  ivith  former  style  below. 

giving  rise  to  the  terms  lateropulsion  and  retropuhion,  and  these  may 
occur  spontaneously  on  getting  up  or  in  attempting  to  stop  while  ad- 
vancing. As  described  by  Stewart,  ^  in  advanced  cases  the  method  of 
getting  into  bed  is  characteristic.  The  patient  climbs  on  to  the  bed, 
stands  up,  and,  bending  down  very  slowly,  grasps  the  rail  at  the  foot- 
board. Holding  firmly  to  the  bedstead  he  slowly  sits  down  and  then 
falls  or  rolls  backward  into  the  recumbent  posture. 

The  trembling-  in  shaking  palsy  may  appear  after  rigidity  has  de- 
veloped or  at  the  same  time.  It  usually  commences  in  one  hand  and 
arm  and  then  invades  the  lower  extremity,  subsequently  appearing  in 
the  opposite  arm  and  finally  in  the  opposite  leg.  In  some  cases  it  is 
bilateral  from  the  start,  but  commonly  it  is  more  marked  on  one  side 
than  on  the  other,  and  may  be  monoplegic  or  more  often  hemiplegic  for 
several  years,  eventually  showing  a  tendency  to  diplegic  distribution. 
Often  it  is  steadily  preceded  in  its  advance  by  the  rigidity,  or  the  rigid- 
ity may  be  generalized  and  of  long  standing  before  tremor  appears  in 
the  hands.  It  affects  the  distal  portion  of  the  extremities  most.  In 
1  "Lancet,"  Nov.  12,  1898. 


550  NEUEOSES. 

the  hands,  where  it  customarily  first  appears  and  is  most  developed,  it 
causes  a  rhythmical,  alternating  flexion  and  extension  of  the  fingers, 
mainly  at  the  metacarpal  joints.  The  tremor  may  be  limited  to  the  index 
and  thumb,  or  aflect  the  interossei  most,  causing  rolling  of  the  fingers 
upon  their  long  axes.  The  patient  appears  to  be  constantly  rolling  some 
small  object,  as  a  pill  or  a  pencil,  between  his  fingers  and  the  opposed 
thumb.  Sometimes  flexion  and  extension  of  the  wrist  are  added,  and 
very  rarely  we  encounter  movements  of  pronation  and  supination.  As 
a  rule,  the  arm  and  shoulders  are  unaffected.  In  the  lower  exti-emity  the 
tremor  predominates  at  the  ankle,  causing  the  foot  to  drum  on  the  floor 
as  if  with  clonus.  The  toes  are  less  evidently  involved  by  tremor,  but 
many  patients  complain  of  flexor  cramping  of  the  toes  as  a  very  early 
condition.  This  usually  comes  on  while  walking,  and  may  bring  the 
patient  to  a  momentary  standstill.  The  muscles  of  the  thigh  often  par- 
ticipate in  the  tremor.  The  muscles  on  the  back  of  the  neck,  shoulders, 
and  dorsum  of  the  body  are  least  afi^ected.  The  abdominal  muscles 
apparently  escape.  In  the  great  majority  of  cases  the  head  does  not 
tremble,  or  only  does  so  by  movements  communicated  to  it  from  a  dis- 
tance. In  very  rare  cases,  however,  there  is  a  rhythmic  nodding,  shak- 
ing, or  rotation  of  the  head  that  may  persist  even  when  the  patient  is 
recumbent.  The  eyelids  exceptionally  are  aflected,  while  the  /?ps  and 
lower  jaiv  not  rarely  show  a  tremor  synchronous  with  that  in  the  hands. 

The  great  peculiarity  of  this  tremor  is  its  usual  occurrence  while  the 
patient  is  at  rest,  during  repose,  and  while  the  parts  are  supported.  In 
a  minority  of  cases,  however,  and  in  other  cases  at  an  early  period,  the 
tremor  is  intentional — that  is,  analogous  to  the  tremor  of  multiple  sclei'osis. 
The  tremor  ceases  during  sleep,  and  usually  it  subsides  momentarily  on 
voluntary  motion.  In  early  cases,  and  particularly  in  cases  presenting 
marked  antecedent  rigidity,  the  tremor  may  only  appear  on  voluntary 
and  sustained  motion,  as  in  reaching  to  the  back  of  the  neck  or  into  a 
distant  pocket,  and  must  be  carefully  sought.  The  tremor  is  a  slow  one, 
of  from  four  to  eight  oscillations  in  a  second.  Usually  the  movements 
are  more  rapid  if  of  limited  extent,  as  when  confined  to  the  fingers,  and 
grow  slower  as  they  involve  larger  muscles.  When  both  upper  or 
all  four  extremities  are  involved  by  the  tremor,  there  is  a  practical 
synchronous  imiformity  of  rhythm  at  all  points.  The  character  of  the 
tremor  shows  distinctly  in  the  handivriting.  The  letters  are  formed 
slowly  and  are  of  fair  proportions,  but  all  the  lines  are  tremulous,  both 
upstrokes  and  stems.  The  writing  tends  to  become  cramped  and  small. 
Sometimes  a  lens  is  required  to  detect  the  tremor  thus  graphically 
demonstrated. 

The  palsy  never  reaches  a  complete  degree,  and  the  paresis  may  be 
•extremely  slight.  While  patients  may  bitterly  complain  of  a  feeling  of 
weakness  and  stifi^ness,  they  often  show  a  normal  amount  of  strength, 
-even  when  the  rigidity  and  tremor  are  very  well  developed.  In  ad- 
vanced cases,  however,  there  is  customarily  some  weakness,  and  this 
may  even  be  extreme.  These  patients,  as  a  rule,  are  loath  to  make  ex- 
ertion of  any  sort. 

Sensory  Disturbances. — The  general  sensibility  is  practically  ob- 


MOTOR  NEUROSES.  551 

jectively  intact,  but  Palmieri  and  Arnaud  ^  insist  that  the  parts  affected 
bv  tremor  show  decided  hypalgesia,  most  intense  in  the  distal  portions 
of  the  limbs  and  gradually  shading  off  toward  the  trunk.  Karplus,^ 
in  a  study  of  103  cases,  never  found  objectively  disturbed  sensation 
without  tremor,  and  subjective  sensory  complaints  were  noted  in  but 
35  per  cent.  Parkinsonians  frequently  complain  of  sutjjective/ee^mj^s 
of  heat,  more  rarely  of  cold,  and  often  of  dull  aches  and  indescribable 
discomfort  in  the  affected  limbs.  The  heat  sensations  may  be  accom- 
panied by  vasomotor  disturbance,  showing  itself  in  elevated  local  tem- 
perature, in  profuse  sweats,  and  in  flushing.  Sometimes  patients  seek 
cool  rooms  and  throw  off  heavy  clothing  and  bed-covering,  even  in 
winter.  In  the  majority  of  cases  complaining  of  heat  the  surface  tem- 
perature is  actually  increased.  In  some  cases  areas  of  brawny  skin  are 
encountered  on  the  brow  or  body,  a  condition  suggestive  of  myxedema 
and  of  scleroderma.  Often  there  is  great  restlessness,  apparently  due 
to  the  discomfort  arising  from  muscular  rigidity.  The  hands  may  be 
frequently  moved  or  the  patient  insists  upon  the  limbs  being  rubljed 
and  moved  about  every  few  minutes.  Muscular  atrophy  only  appears 
in  advanced  cases,  but  even  then  is  not  extreme.  There  are  no  electrical 
<;hanges  or  sphincter  weakness.  As  this  is  a  disease  of  the  involutional 
period  of  life,  we  may  find  all  the  disturbances  of  senility  as  coinci- 
dental accessories. 

The  mental  state  is  likely  to  be  mistaken  for  one  of  dementia,  but, 
as  a  rule,  these  patients  enjoy  all  their  mental  powers.  There  is,  how- 
ever, the  same  inertia  in  the  mental  processes  that  marks  the  muscular 
state.  They  shun  exertion,  are  chary  of  their  thoughts,  talk  little, 
appear  indifferent,  and  often  require  the  incentive  of  strange  faces  or 
extraordinary  circumstances  to  arouse  them  to  a  show  of  mental  activity. 
This,  taken  with  their  inexpressive  faces,  is  easily  misleading. 

Course. — The  disease  is  essentially  chronic  and  progressive.  The 
onset,  insidious,  as  a  rule,  may  be  abrupt,  folloAving  some  mental  or 
physical  storm.  The  duration  is  from  ten  to  forty  years.  In  the 
extremely  protracted  cases  the  patients  become  more  and  more  helpless, 
fall  into  a  senile  dementia,  and  die  from  intercurrent  disease,  usually 
pneumonia.  Varieties  have  been  described,  but  they  are  usually  limited 
and  undeveloped  cases.  Thus,  the  monoplegic  and  hemiplegic  forms, 
the  form  without  tremor,  the  form  without  rigidity,  and  the  form  show- 
ing extension  are  named.  The  prognosis  is  bad,  but  there  may  be 
remissions. 

Diagnosis. — In  typical  cases  the  diagnosis  is  made  at  a  glance.  In 
early  and  undeveloped  cases  Parkinson's  disease  may  be  mistaken  for 
posthemiplegic  trembling,  but  lacks  the  history  of  a  stroke.  Senile  trem- 
bling usually  first  affects  the  head  and  does  not  present  the  facies  and 
rigidities,  but  intermediate  cases  may  be  found  and  both  may  coexist. 
Multiple  sclerosis  has  its  increased  reflexes  and  intention  tremor,  hysteria 
its  stigmata. 

Treatment. — If  seen  early,  the  case  should  be  treated  as  one  of 
-cerebral  arteriosclerosis  (see  p.  199).     In  several  instances  this  plan  of 

1  "Clinica  Med.  Ital.,"  No.  6.  ^  "  jahrb.  f.  Psych,  u.  Neurol.,"  1900. 


552  NEUROSES. 

treatment  has  seemed  to  retard  the  development  of  the  disease.  Symp- 
tomatic medication  is  practically  useless.  Opium,  hyoscin,  and  cannabis 
indica,  if  given  freely,  temporarily  control  the  tremor,  but  at  the  ex- 
pense of  the  general  health  and  welfare.  Massage,  electricity,  and 
strychnin  give  a  little  help  for  the  time  being  in  some  cases.  Persistent 
exercises, — both  passive  and  active, — Swedish  joint-movements,  and 
gentle  muscle  kneading,  if  intelligently  carried  out  for  a  long  period  of 
time,  certainly  benefit  these  patients  in  the  earlier  stages.  Mental  and 
physical  fatigue  must  be  avoided.  Charcot  noticed  that  the  vibrations 
experienced  in  carriage-  and  car-riding  mitigated  the  tremor,  and  treated 
many  cases  by  means  of  a  jolting  or  vibrating  chair  with  temporary 
benefit. 


THOMSEN'S  DISEASE  (MYOTONIA), 

In  1876  Thomsen,  himself  subject  to  the  disease,  fully  described  a 
muscular  condition  later  called  myotonia  congenita,  family  myotonia,  etc. 
It  is  a  disorder  manifest  in  the  voluntary  muscles,  which  show  a  stiff- 
ness and  rigidity  upon  attempted  use  after  a  period  of  repose,  and  certain 
peculiarities  of  mechanical  and  electrical  irritability.  It  is  a  rare  dis- 
ease, numbering  not  more  than  a  hundred  recorded  cases. 

Etiology. — The  salient  etiological  feature  of  the  infirmity  is  heredity. 
Most  of  the  known  cases  have  been  in  family  groups,  sometimes  ex- 
tending over  several  generations  and  through  several  collateral  branches. 
Occasionally  the  disorder  has  passed  over  a  generation  and  again 
appeared.  With  and  without  direct  heredity  the  family  history  is 
commonly  surcharged  with  neuroses  and  psychoses.  Males  are  appar- 
ently the  more  commonly  aflPected.  Von  JBechterew  ^  suggests  that  a 
self-poisoning  or  auto-intoxication  is  active  in  this  condition,  and  Jacoby  ^ 
looks  upon  the  disease  "  as  due  to  an  embryonal  developmental  disorder 
of  the  nerve-cells,  consisting  in  the  more  or  less  diminished  resistance 
of  the  cells  to  the  influence  of  toxic  processes."  The  disease  is  also 
related  to  the  myopathies,  as  shown  by  the  muscular  contours  and  the 
occasional  appearance  of  atrophy.  ^ 

Morbid  Anatomy. — Various  observers,  upon  examination  of  excised 
fragments  of  the  aifected  muscles,  have  recognized  a  hypertrophy  of  the 
protoplasm  and  nuclei  and  a  deficiency  of  striation  in  the  enlarged 
muscle-fibers,  usually  with  slight  but  insignificant  increase  of  interstitial 
tissue.  This  constitutes,  according  to  Deleage,  a  persistence  of  embryonal 
conditions.  Jacoby  insists  that  this  appearance  is  an  artifact  that  is 
not  found  if  the  tissue  removed  during  life  is  not  allowed  to  contract. 
Babes  and  Marinesco  have  noted  deformity  or  maldevelopment  of  the 
terminal  motor-nerve  plaques.  In  the  only  autopsy  yet  recorded, 
Dejerine  and  Sottas^  found  no  changes  in  medulla,  cord,  or  peripheral 
nerves.  It  is  as  yet  impossible  to  say  whether  we  have  to  deal  with  a 
pure  myopathy,  a  trophoneurosis,  or  a  congenital  defect  in  the  trophic 
and  motor  apparatus  of  the  cord. 

1  "Neurol.  CentralbL,"  Feb.,  1900.         ^  «  jo^r.  Nerv.  and  Ment.  Dis.,"  July,  1898. 
3  Bernhardt,  "Allg.  med.  Centralzelt. , "  No.  14, 1899.     *  "Rev.  deM6d.,"  Mar.,  1893. 


310 TOE  NEUROSES.  553 

Symptoms. — The  awkwardness  caused  by  the  fixity  of  the  muscles 
upon  attempted  use  is  noticed  in  infancy,  or  may  appear  at  any  time  up 
to  the  twentieth  year,  or  perhaps  even  later.  In  typical  cases,  when 
the  subject  desires  to  execute  some  movement,  a  more  or  less  marked 
and  prolonged  contraction  fixes  the  muscles  in  question.  This  gradually 
subsides  and  the  movement  is  accomplished.  Repetitions  of  the  spasms 
occur  progressively  witli  less  force  and  duration  for  the  particular  action, 
and  finally  cease  to  appear,  but  any  change  in  the  character  or  even  in 
the  rhythm  of  the  movements  may  reinstate  the  muscular  fixation. 
Thus,  in  risino;  from  a  chair  the  leo;s  and  thiohs  are  held  rioidlv.  Once 
erect,  the  first  step  is  impeded,  the  second  less  so,  and  finally  steps  are 
taken  with  natural  ease,  but  a  halt,  a  sharp  turn,  or  even  a  change  of 
speed  may  again  set  up  the  spasm.  All  the  voluntary  muscles  may  be 
aiFected,  even  to  those  of  the  thorax,  eye,  and  tongue,  but  usually  the 
myotonia  is  most  marked  in  the  lower  extremities,  and  in  some  cases  the 
face  and  upper  extremities  escape.  The  congenital  paramyotonia  of 
Eulenberg,  in  which  symmetrical  groups  of  muscles  are  affected  mainly 
on  direct  exposure  to  cold,  appears  to  be  a  limited  form  of  Thomsen's 
disease.  Both  varieties  have  been  observed  in  the  same  patient  by  Bern- 
hardt. ^  The  sphincters  and  unstriped  muscles  escape,  and  in  the  case 
mentioned  by  Eulenberg  the  heart-muscle  was  normal.  Gaping,  sneez- 
ing, cold,  wet,  fatigue,  and  emotional  excitement  provoke  the  spasms, 
while  warmth,  moderate  exercise,  repose,  and  quietude  diminish  their 
intensity.  They  are  in  some  measure  relative  in  intensity  to  the  vigor 
of  the  attempted  movement. 

Commonly,  the  aifected  muscles  are  of  unusual  firmness  and  increased 
bulk,  but  of  lessened  power,  giving  an  appearance  of  athletic  develop- 
ment at  variance  with  the  actual  weakness,  in  manv  cases  suo-sfestinsr  a 
pseudohypertrophy.  They  are  perfectly  supple  to  passive  movements. 
The  reflexes  are  normal,  but  a  tap  on  the  tendon  is  likely  to  produce  a 
spasm  in  the  anterior  femoral  group,  modifying  the  usual  response. 
Electrical  and  mechanical  excitations  of  the  motor  nerve-trunks  produce 
perfectly  normal  responses,  or  they  are,  if  anything,  somewhat  dimin- 
ished. In  the  muscles  it  is  very  diiferent.  A  slight  blow,  as  with  a 
percussion  hammer,  produces  a  persisting  welt  from  localized  muscular 
swelling  or  myoidema.  The  galvanic  current  produces  sluggish,  pro- 
longed contractures  upon  closure  almost  equally  with  either  pole.  Anodal 
or  cathodal  closing  tetanus  may  often  be  secured  with  the  continuous 
passage  of  five  to  ten  milliamperes  of  current,  and  anodal  opening  tetanus 
is  not  infrequently  observed.  The  strong  faradic  current  produces  undu- 
latory  contractions  in  many  muscles,  and  these  sometimes  attend  the 
passage  of  the  continuous  current.  Repeated  electrical  or  mechanical 
stimulation  of  the  muscles,  like  volitional  use,  gradually  exhausts  the 
myotonic  responses. 

As  varieties,  Jacoby  would  limit  the  terra  congenital  myotonia  to 
cases  (1)  presenting  a  hereditary  etiology  either  as  a  direct  transfer 
from  the  ascendant,  or  by  inherited  disposition  ;  (2)  manifesting  the 
myotonic  disorder  of  movement — namely,  intention  spasm  ;  (3)  showing 

^  Loc.  cit. 


554  NEUBOSES. 

the  myotonic  reaction,  which  he  describes  as  made  up  of  normal 
mechanical  and  faradic  excitability  of  the  nerves  and  increased  mechan- 
ical and  faradic  excitability  of  the  nmscles,  anodal  and  cathodal  con- 
tractions being  equal  and  the  response  always  being  tonic  and  prolonged ; 
(4)  persisting  hypertrophy  of  the  enlarged  muscles  ;  and  (5)  absence 
of  symptoms  pointing  to  gross  involvement  of  the  nervous  system. 
Other  varieties  of  myotonia  he  would  denominate  myotonia  aquisita^  as 
describing  those  acquired  subsequent  to  birth,  and  myotonia  transitoria 
for  the  cases  due  to  exposure  to  cold,  etc. 

Psychie  disorders  are  frequently  associated,  but  not  necessarily  present. 
The  malady,  once  developed,  tends  to  persist  for  life,  which  it  does  not 
abridge.  It  is  an  incurable  infirmity,  but  sometimes  shows  arrest  or 
amelioration. 

Diagnosis. — The  myoidema  and  myotonic  electrical  reactions,  taken 
with  the  intention  spasm,  if  the  term  may  be  used,  make  the  diagnosis 
easy.  Tetany  has  its  distinctive  signs  in  the  phenomena  of  Trousseau  and 
Chvostek.  Pseudohypertrophic  paralysis  has  peculiar  deformities,  con- 
tractures, and  weakness  without  intention  cramps.  It  subsequently 
shows  atrophies  and  has  no  myotonic  reactions. 

Treatment. — The  causes  which  provoke  the  myotonic  cramps,  such 
as  overexertion,  fatigue,  exposure  to  cold,  and  excitement  of  all  sorts, 
must  be  avoided.  Massage,  reasonable  exercise,  electric  baths,  and 
cerebral  galvanization  have  been  recommended.  ^  A  careful  search  for 
toxic  factors  should  be  made,  and  conditions  known  to  be  attended  by 
them  should  be  corrected. 


FAMILY  PERIODIC  PARALYSIS. 

There  is  a  form  of  periodic  limp  paraplegia  that  may  be  designated 
family  j^eriodic  paralysis.  It  is  characterized  typically  by  recurring 
attacks  of  pure  flaccid  motor  palsy,  most  pronounced  in  the  lower  ex- 
tremities, marked  by  diminished  reflexes  and  lessened  electrical  and 
mechanical  muscular  excitability.  The  intervals  are  those  of  ordinary 
health,  and  there  is  a  decided  family  and  hereditary  tendency. 

The  first  definite  outline  of  this  condition  was  given  by  Westphal, 
in  1885.  Additional  material  has  been  contributed  by  Goldflam,  Op- 
penheim,  Bernhardt,  Hirschl,  and  other  German  observers,  and  by 
Burr,  Taylor,  Mitchell,  Putnam,  and  Crafts  in  this  country.  Oddo 
and  Audibert  ^  were  able  to  collect  64  published  cases. 

Etiology. — Heredity  is  most  apparent.  Taylor  noted  that  thirty-five 
cases  had  been  reported  in  three  families,  nineteen  in  one  of  them,  and 
in  two  instances  it  had  appeared  in  five  consecutive  generations,  descend- 
ing through  both  sexes,  which  are  about  equally  represented.  jSTearly 
all  known  cases  presented  attacks  before  the  age  of  twenty-five,  the  great 
majority  in  youth,  rarely,  however,  before  the  tenth  year  of  life.  The 
inciting  causes  of  the  attacks  have  been  exertion,  fatigue,  and  mental 
strains.     Goldflam,  in  1890,  suggested  that  there  was  an  autotoxic  causa- 

1  W.  von  Bechterew,  "  Neiirolog.  Centralbl.,"  Nov.,  1897. 

2  "  Arch.  gen.  de  Med.,"  1902. 


MOTOR  NEUROSES.  555 

tion  acting  upon  an  inherited  vulnerability  of  motor  nerve-cells,  and 
Crafts  ^  and  Irwin  have  been  able  to  isolate  an  extractive  from  the  feces 
passed  immediately  after  an  attack  which  produced  temporary  paralysis 
when  injected  into  rabbits  and  guinea-pigs.  The  amount  of  urea  ex- 
creted during  the  attack  also  appears  to  be  diminished.  These  results 
have  not  been  confirmed.  ^  Somewhat  analogous  attacks  due  to 
malarial  infection  have  been  cured  by  quinin.  The  muscular  contours, 
and  in  Bernhardt's  case  atrophy  of  the  thenar  eminences  and  continued 
muscular  weakness,  imply  a  relationship  to  the  progressive  muscular 
atrophies  and  to  the  myotonias.  Examination  of  muscular  fibers  taken 
from  the  living  subject  also  indicates  a  similar  kindred. 

Symptoms. — The  attacks  come  on  rather  slowly  within  a  few  hours, 
usually  at  night  or  during  sleep.  They  are  sometimes  preceded  by  a 
feeling  of  weariness,  numbness,  formication,  sweating,  heat,  desire  to 
urinate,  headache,  backache,  rapid  pulse,  coldness  of  the  legs,  etc.,  in 
various  cases,  but  all  prodromata  may  be  lacking.  The  lower  extremities 
are  uniformly  most  affected,  and  the  paralysis  may  be  limited  to  them, 
but  in  other  instances  involves  every  skeletal  muscle  except  those  con- 
trolled by  the  cranial  nerves,  so  that  the  patient  is  inert  from  the  chin 
downward.  A  facial  weakness  has  been  observed  in  one  case.  Even 
the  voice  and  respiratory  efforts  may  be  weak,  sneezing  and  coughing 
impossible,  and  the  heart  has  in  certain  instances  been  found  dilated  and 
with  evidence  of  mitral  insufficiency,  both  disappearing  with  the  attack. 
Such  attacks  last  from  an  hour  to  a  week  and  tend  to  uniformity  in  a 
given  case.  The  paralysis  recedes  in  the  reverse  order  of  invasion. 
Attacks  may  recur  daily,  weekly,  or  once  in  several  years. 

During  the  attack  electrical  responses  in  nerve  and  muscle  and  the 
tendon  reflexes  are  lessened  or  completely  abolished,  but  there  is  neither 
reaction  of  degeneration  nor  sphincteric  incompetence.  Mechanical 
stimulability  of  the  muscles  and  nerves  also  disappears.  The  mind  and 
general  sensation  and  the  special  senses  are  unimpaired.  The  attack 
subsides  about  as  rapidly  as  it  develops,  and  in  the  intervals  the  health 
is  usually  perfect.  Indeed,  many  of  these  patients  are  described  as 
unusually  robust  and  commonly  very  muscular.  The  muscular  contours 
at  times  have  even  suggested  the  myopathic  family  disorders. 

Diagnosis. — The  diagnosis  in  familial  cases  should  be  easily  made. 
In  sporadic  instances  the  behavior  of  the  reflexes,  electrical  and  me- 
chanical responses,  periodic  recurrence  and  absence  of  mental  and 
sensory  disturbances,  should  be  sufficiently  definite  to  distinguish  the 
condition  from  hysteria,  with  which  it  has  been  confounded.  A  first 
attack  may  suggest  Landry's  paralysis,  but  again  reliance  may  be  placed 
on  the  quantitative  electrical  change. 

Prognosis  and  Treatment. — Thus  far  no  treatment  has  been  of 
much  service,  but  those  conditions,  such  as  fatigue,  which  appear  capable 
of  inducing  attacks  in  given  instances  must  be  avoided.  The  tendency 
is  for  the  disease  to  endure  for  life  without  compromising  it.     A  further 

1  "  Am.  Jour.  Med.  Sciences,"  June,  1900. 

2  Mitchell,  Flexner,  Edsall,  "Brain,"  1902.    Singer,  "Brain,"  1901. 


556  NEUEOSES. 

knowledge  of  the  toxic  states  may  furnish  the  key  both  to  the  pathology 
and  treatment  of  this  rare  disease. 


FAMILY  TREMOR. 

A  tremulous  condition,  particularly  of  the  hands,  but  also  in  some 
instances  involving  the  head,  face,  and  tongue,  closely  resembling  the 
tremors  of  multiple  sclerosis,  senility,  alcohol,  and  mercury,  is  encoun- 
tered as  a  family  trait.  It  may  be  traced  through  several  or  many  gen- 
erations, and  affects  a  large  proportion  of  the  family  members,  appearing 
before  forty  and  usually  before  twenty  years  of  age. 

The  majority  of  such  families  are  markedly  neurotic,  and,  accord- 
ing to  Raymond,  the  tremor  may  be  considered  as  a  stigma  of 
degeneracy.  In  character  the  tremor  is  usually  fine  and  rapid.  It  is 
accentuated  by  effort,  fatigue,  and  emotion,  ordinarily  does  not  occur 
during  rest,  but  generally  closely  resembles  the  intention  tremor  of 
multiple  sclerosis. 


CHAPTER   IV. 
FATIGUE  NEUROSES. 

Many  occupations  requiring  the  constant  repetition  of  certain  pre- 
cise muscular  movements  may,  eventually,  through  overuse  and  fatigue, 
give  rise  to  disturbances  of  muscular  control  for  the  manoeuver  in 
question.  The  condition  may  be  manifest  as  pain,  tremor,  weakness, 
or  cramp,  but  usually  these  are  variously  combined  in  different  cases. 
This  group  of  motor  disturbances  is  also  called  occupation  spasms  or 
occupation  neuroses.  Many  of  them  are  described  under  terms  indi- 
cating their  particular  avocational  association,  as  scriveners'  palsy,  piano- 
players'  cramp,  seamstresses'  spasm,  etc.  We  may  take  writers'  cramp, 
the  most  commonly  encountered  one,  as  a  type,  and  then  only  an 
enumeration  of  the  other  forms  wall  be  needed.  The  more  delicate  and 
highly  differentiated  the  functional  movements,  the  more  readily  does 
their  repeated  overfatigue  set  up  this  inhibitory  condition.  No  definite 
anatomical  changes  have  been  found,  but  it  is  highly  probable  that 
improved  methods  will  demonstrate  morphological  alteration  of  the 
nuclear  gray.  Vigouroux  ^  claims  to  have  found  changes  in  nerves  and 
muscles  in  many  cases,  and  supposes  them  to  be  present  in  all. 

1  "Progrfes  Medicale,"  quoted  in  "Amer.  Medico-Surg.  Bulletin,"  Jan.  25,  1897. 


FATIGUE  NEUROSES. 


557 


WRITERS'  CRAMP. 

Writers'  cramp  is  variously  known  as  scriveners'  palsy,  grapho- 
spasmus,  mogigraphia,  chirospasm,  etc. 

Etiology. — A  neuropathic  heredity  and  a  neurotic  make-up  are 
very  conunon  among  sufferers  from  writers'  cramp.  The  neurosis  has 
exceptionally  been  noted  in  brothers  and  in  parents  and  children,  but, 
ordinarily,  there  is  merely  a  transmitted  nervous  tare  constituting  a 
tendency  to  the  development  of  the  disorder  under  the  provocation  of 
overuse  of  a  certain  functional  group  of  muscular  movements.  It  is 
much  more  common  in  the  male  than  in  the  female  sex,  perhaps  owing 
to  the  greater  proportion  of  men  engaged  with  the  pen.  It  most  com- 
monly develops  between  twenty  and  fifty  years  of  age,  being  very  rare 
before  and  after  these  extremes.  Its  greatest  incidence  is  between 
twenty-five  and  thirty-five.  It  is  very  likely  to  appear  during  periods 
of  physical  or  mental    strain,  especially  after  protracted  anxiety  arising 


Fig.  239. — Unstimulated  cell  from  poste- 
rior spinal  gangliou  of  cat  (from  Hodge,  after 
Tukej. 


Y\s.  240. — Cell  from  posterior  spinal  gan- 
glion of  cat.  First  ett'ect  of  stimulation  (from 
Hodge,  after  Tuke). 


from  any  cause.  Occasionally,  some  local  injury  to  the  hand  or  arm 
wdiich  entails  additional  difficulty  in  the  mechanical  process  of  writing 
may  serve  to  provoke  it.  Neuritis,  neuralgia,  and  hemiplegia  affecting 
the  writing  arm  have  been  followed  by  the  neurosis.  The  principal 
inciting  cause  of  the  trouble  is  excessive  icriting  in  a  had  manner — that  is, 
in  any  style  that  depends  upon  the  employment  of  the  small  muscles  of 
the  hand,  wrist,  or  forearm  in  chief,  and  in  which  the  writing  move- 
ments are  not  made  entirely  from  the  shoulder.  Thus,  writers'  cramp  is 
practically  unknown  among  stenographers,  in  spite  of  the  rapidity  and 
tediousness  of  their  work,  owing  to  the  fact  that  the  characters  employed 
are  best  made  by  the  freehand  method  customarily  employed.  Gowers, 
indeed,  encountered  a  stenographer  who  could  write  shorthand  readily, 
while  ordinary  script  caused  a  spasm. 

Pathology. — Numerous  theories  have  been  advanced  regarding  the 


558 


NEUROSES. 


pathology,  and  the  seat  of  the  disease  has  been  variously  placed  in  the 
muscles,  in  the  nerves,  in  the  spinal  centers,  in  the  cerebellum,  and  in 
the  cortex.  We  can,  at  once,  rule  out  the  muscle  and  the  nerve  as 
initial  loci,  because  in  ordinar}^  cases  the  muscular  control  for  movements 
not  of  the  particular  occupational  variety  are  fully,  promptly,  and  nor- 
mally executed.  It  is  impossible  to  conceive  of  a  peripheral  lesion 
which  would  disturb  only  a  certain  purposive  function,  leaving  others 
intact.  In  most  all  cases  the  motor  function  at  fault  is  one  to  which 
the  motor  apparatus  has  become  trained  and  habituated.  In  some 
degree  it  is  automatic  and  subconscious.  Such  acts  are  generally  sup- 
posed to  be  largely  subcortical.  Another  factor  is  interposed  by  the 
fatigue  element.  Hodge  has  clearly  demonstrated  the  changes  in  motor 
cells  resulting  from  physiological  fatigue.  In  the  occupation  neuroses 
it  is  at  least  supposable  that  the  fatigue  may  overpass  the  limit  of  recu- 
peration. Well-authenticated  cases  in  which  muscular  atrophy  has 
succeeded  the  spasm  would  indicate  rather  conclusively  that  such  was 

the  case,  that  the  motor  cells  of  the 
cord  were  at  fault,  and  that  their 
trophic  powers  were  finally  involved. 
Sensory  and  motor  symptoms,  func- 
tionally grouped,  would  also  point 
to  the  cord,  but  it  is  impossible  as 
yet  to  exclude  the  superior  cortical 
centers. 

Symptoms. — The  onset  of  writ- 
ers' cramp  is  commonly  insidious. 
It  is  noticed  after  writing  a  con- 
siderable time  that  there  is  sensory 
discomfort  or  motor  difficulty.  The 
hand  aches,  feels  numb  or  weak,  or 
may  become  cramped  or  tremulous. 
After  a  moment's  rest  and  a  little 
rubbing  writing  may  be  resumed 
for  a  time,  when  the  trouble  reap- 
pears and  gradually  less  and  less  work  is  required  to  induce  the 
disabling  condition,  until  in  extreme  cases  merely  putting  the  hand  in 
the  writing  position  may  cause  it.  Several  forms  have  been  described 
depending  upon  the  major  symptom.  Thus  we  have  the  spastic,  tremulous, 
neuralgic,  and  jmrali/tiG  varieties ;  but  they  are  very  rarely  pure,  most 
cases  showing  a  combination  of  sensory  and  motor  features.  Ordinarily, 
the  cramp  is  painful  not  from  the  muscular  contraction,  but  because  the 
parts  are  affected  with  neuralgic  pains  that  are  occasioned  only  by  the 
act  of  writing.  In  some  instances  they  are  so  severe  as  to  alone  attract 
the  patient's  attention  and  inhibit  the  act  of  writing.  In  other  and 
much  rarer  cases  a  feeling  of  weakness  appears  to  prevent  the  use  of 
the  pen,  but  it  is  usually  associated  with  pain.  Tremor  may  be  the 
principal  feature,  and  is  practically  a  manifestation  of  weakness. 

Motor  Disorders. — In  the  case,  Fig.  242,  illustrated  from  photo- 
graphs, the  plan  of  holding  the  pen  between  the  index  and  middle  fingers 


Fig.  241. — Cell  from  posterior  spinal  gan- 
glion of  cat.  Later  effect  of  stimulation  (from 
Hodge,  after  Tuke). 


FATIGUE  NEUROSES. 


559 


Avas  adopted  when  spasm  first  developed,  and  for  a  time  permitted  a 
continuation  of  clerical  work.  When  seen  later,  the  hand  would  begin  to 
cramp  after  half  a  dozen  words  were  written,  as  shown  in  the  second 
cut,  and  in  a  moment  the  spasm  would  become  violent,  the  pen  would 
fall,  and  the  fingers  and  thumb  would  be  extended  as  shown  in  the  third 
cut.  This  was  an  aggravated  case.  Commonly,  as  soon  as  the  spasm 
causes  uncertainty  in  writing  the  act  is  stopped  and  the  spasm  subsides. 
It  may  cause  a  great  change  in  the  writing,  which  tends  to  become 
cramped  and  full  of  uncertainties  and  zigzags.  The  pen  is  forcibly 
jerked  and  thrust  in  various  directions.  At  first,  by  steadying  the 
writing  hand  with  the  other,  and  adopting  a  thick  penholder  or  one 
fitted  with  a  ball  held  in  the  palm  of  the  hand  or  with  rings  against 
which  the  fingers  are  pressed  in  extension,  writing  may  be  continued  for 
a  time,  but  usually  the  spasm  reappears.  If  the  other  hand  be  then 
used,  it  is  not  uncommon  for  the  spasm  to  appear  on  that  side  after  a 
few  months,  though  this  is  not  invariably  the  case.  When  the  spasm 
affects  the  second  hand,  it  may  also  cause  the  muscles  of  the  first  hand  to 


Fig.  242. — Writers'  cramp  (from  photographs) :  1,  Pen  held  between  tingers  at  first  gave  relief; 
2,  spasm  beginning  in  thumb  and  index  ;  3,  fully  developed  spasm,  throwing  all  the  digits  except  small- 
est finger  into  extension  and  causing  the  pen  to  fall. 


contract.  The  spasm  may  also  spread  to  the  muscles  of  the  forearm 
and  even  to  the  arm  and  shoulder. 

In  cases  of  moderate  severity  the  spasm  may  be  occasioned  only  by 
the  act  of  writing,  but  sometimes,  and  in  severe  cases  usually,  other 
acts  requiring  precision  in  finger  movements  also  call  it  forth.  In 
telegraphers'  cramp,  writing  with  the  Morse  key  or  the  pen  often  alike 
causes  the  spasm  ;  musicians  may  experience  the  spasm  both  in  instru- 
mental manipulations  and  in  writing ;  seamstresses  by  using  the  needle 
or  the  scissors,  etc. 

The  power  of  the  hand  for  coarse  muscular  efforts  may  be  unim- 
paired, but  in  cases  of  long  standing  some  weakness  in  the  muscles  most 
concerned  is  commonly  found,  and  in  such  cases  slight  wasting  may 
occur.  In  rare  instances,  when  the  use  of  the  affected  member  is 
pushed  in  spite  of  the  disability,  permanent  atrophy  may  result.  In 
figure  244  is  shown  the  hand  of  a  seamstress  in  which  local  pain  and 
spasm  were  finally  followed  by  atrophy,  the  reaction  of  degeneration, 
and  fibrillary  twitching  limited  mainly  to  the  radial  half  of  the  hand  and 
ulnar  border  of  the  forearm,  namely,  to  the  muscles  chiefly  concerned  in 
the  use  of  needles  and  scissors.    The  electrical  responses  in  muscles  and 


560 


NEUROSES. 


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3 


ST^ 


7 


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3 

3 


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-^-^^-<-' <lX-<Z— 


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Fig.  243. — 1,  Writers'  cramp,  handwriting  in  1894;  2,  copy  of  same  made  very  slowly  in  1897  by  same 
patient ;  3,  written  by  aid  of  left  hand,  same  patient,  1897  ;  4,  same  patient,  1897. 


FATIGUE  NEUROSES.  561 

nerves  may  be  normal,  but  in  protracted  cases  there  is  usually  an 
increase  and  finally  a  decrease  of  excitability,  and,  as  in  the  rare  case 
illustrated  below,  the  reaction  of  degeneration  may  be  present. 

Sensory  Disorders. — The  sensory  disturbance  is  sometimes  de- 
scribed as  one  of  great  fatigue,  or  there  may  be  pain  and  tenderness. 
Tenderness  along  the  course  of  the  nerves  is  not  uncommon.  In  some 
cases  pain  is  located  in  the  small  bones  and  joints  of  the  wrist  or 
fingers.  It  may  only  occur  on  attempts  to  write,  and  it  may  or  may 
not  be  preceded  by  spasm.  In  certain  cases  it  extends  to  the  arm, 
axilla,  and  shoulder.  Such  paresthesias  as  "  pins  and  needles,"  ting- 
ling, ache,  ''tired  feeling,"  etc.,  are  often  complained  of,  and  may 
similarly  extend  up  the  arm.  Actual  hyperesthesia  or  anesthesia  are 
encountered  only  when  neuritis  is  associated. 

Course. — Commonly  iusidious  in  onset,  writers'  cramp  may  develop 
with  some  suddenness,  after  an  emotional,  moral,  or  physical  storm,  and 
tends  to  progress  so  long  as  writing  is  persistently  attempted.  If  the 
opposite  hand  be  trained,  it  usually  also  becomes  the  seat  of  cramp,  which 
is  likely  to  increase  more  rapidly  than  on  the  side  first  affected.  If 
writing  be  completely  abjured,  the  cramp  gradually  becomes  less  and 


•ig.  244.— Wastiug  of  muscles  in  a  severe  case  of  seamstress'  cramp. 


less,  and  may  entirely  cease  after  a  few  months  or  a  year,  but  is  very 
likely  to  return  if  continuous  writing  is  again  taken  up.  The  tendency 
of  the  cramp,  pains,  and  paresthetic  sensations  to  persist  and  increase 
if  the  writing  occupation  is  continued  is  pronounced,  and  there  is 
danger  of  pushing  the  condition  into  one  of  organic  changes,  with 
atrophy  and  permanent  palsies. 

Diagnosis. — The  diagnosis  is  usually  made  by  the  patient,  and 
jiearly  every  large  clerical  force  and  telegraph  office  furnish  cases. 
Monoplegia  and  hemiplegia  from  organic  brain  disease  are  some- 
times mistaken,  as  the  patient's  attention  is  first  attracted  by  his  clum- 
siness in  writing,  Musculospiral  palsy,  neuralgias,  and  rheumatic  pains 
are  occasionally  mistaken  for  writers'  cramp,  but  in  all  these  condi- 
tions the  symptoms  are  persistent  and  not  alone  provoked  by  writing. 
Spasm,  usually  present  in  writers'  cramp  from  the  first,  is  also  absent. 
Hysteria  may  present  limited  tremor  and  motor  difficulty,  but  the  dis- 
ability is  not  confined  to  writing,  and  sensory  stigmata  are  added. 

Prognosis. — The  prognosis  is  very  unfavorable  if  writing  be  per- 
jsisted  in.  If  the  patient  can  completely  abstain  from  the  use  of  the  pen 
36 


562  NEUROSES. 

or  similar  writing  implements,  the  spasm  tends  to  subside  and  disappear 
unless  the  case  is  of  long  standing  and  so  aggravated  that  all  sorts  of 
finger  use  induce  the  cramp.  The  neuralgic  cases  are  somewhat  more 
easily  managed  than  the  cramp  variety  if  prolonged  rest  can  be  secured. 
The  presence  of  any  removable  diathetic  disability,  as  lithemia,  favorably 
modifies  the  outlook,  and  the  termination  of  general  depression,  physical 
or  mental,  may  lead  to  marked  improvement  in  the  spasmodic  affection. 
The  tendency  to  recurrence  and  to  extension  has  already  been  noted.  It 
is  rare  for  a  patient,  even  after  years  of  rest,  to  be  able  to  return  to 
w'riting  occupations  without  a  reappearance  of  the  neurosis. 

Treatment. — Recognizing  the  fatigue  element  in  the  production  of 
writers'  cramp,  rest  becomes  the  principal  note  of  treatment.  All 
physical  failings  and  conditions  which  tend  to  make  fatigue  of  ready 
appearance  must  be  scrupulously  sought  and  carefully  managed.  Abso- 
lute cessation  of  writing  is  of  the  first  importance.  Unfortunately, 
patients  whose  living  depends  upon  clerical  work  will  not  or  can  not 
conform  to  these  requirements  until  the  neurosis  completely  disables 
them.  Exercises  to  develop  the  strength  of  the  arms,  hands,  and 
fingers  should  be  employed,  and  massage,  baths,  and  electricity,  for  their 
general  tonic  eifect,  are  of  some  service.  When  writing  is  again  taken 
up,  it    must    be    by  the   proper   full-arm    movement.     A    typewriting 


Fig.  245. — 1,  Splint  to  immobilize  hand  and  wrist  in  the  treatment  of  writers'  cramp;  2,  splint  id  use. 

machine  can  often  be  substituted  for  the  pen.  The  use  of  spinal 
sedatives  to  control  the  cramp  and  permit  a  continuance  of  writing  is 
pernicious,  and  rarely  gives  even  temporary  help.  When  writing  is 
resumed,  the  free-hand  method  from  the  shoulder  must  be  employed,  and 
the  splint  (Fig.  245)  affords  a  help  by  immobilizing  the  wrist  and 
fingers  during  writing  exercises. 


OTHER   OCCUPATION   NEUROSES. 

The  general  considerations  pertaining  to  writers'  cramp  are  equally 
applicable  to  the  other  occupation  neuroses,  and  with  proper  modi- 
fication the  particular  features  are  identical.  Among  the  occupa- 
tion spasms  more  commonly  encountered  are  the  cramps  of  violin  and 
pianoforte  players,  telegraphers'  cramp,  seamstress'  cramp,  and 
hammer    cramp    in   smiths  and   artisans  using  the  hammer.     Artists,. 


NEURASTHENIA.  563 

flower-makers,  turners,  watchmakers,  knitters,  engravers,  masons  in 
using  the  trowel,  sailors  from  pulling  on  ropes,  treadlers,  compositors, 
enamelers,  cigarette-makers,  shoemakers,  milkers,  money-counters, 
letter-sorters,  and  players  on  various  musical  instruments,  including 
drummers,  comprise  the  list  given  by  Gowers.  It  has  been  noted  in  a 
shoe  salesman  from  the  stooping  position  needed  in  putting  on  shoes,  in 
gum-chewers,  aifecting  the  masticatory  muscles,  and  in  various  factory 
employees  who  incessantly  use  the  same  movement  in  feeding  or  at- 
tending some  machine.  Clergymen  and  other  public  speakers,  from  a 
faulty  use  of  the  vocal  apparatus,  may  acquire  a  laryngeal  neurosis  that 
is  manifest  every  time  the  voice  is  strained,  causing  a  sudden  loss  of 
modulation,  which  may  end  in  continuous  vocal  disability.  A  spasm  of 
a  similar  nature,  involving  the  lumbar  muscles,  has  been  seen  in  physi- 
cians, due  to  continuous  riding  in  carts  or  buggies. 


CHAPTER  V. 
NEURASTHENIA, 

In  1869  Beard,  of  New  York,  directed  general  attention  to  a 
nervous  state  or  condition  marked  by  irritable  weakness,  and  adopted 
for  it  the  name  of  neurasthenia.  It  is  familiarly  known  as  nervous 
prostration  or  nervous  exhaustion,  and  is  a  fatigue  neurosis.  In  Europe 
it  was  at  first  somewhat  derisively  called  the  American  disease  or  BearcVs 
disease.  It  is  now  recognized  the  world  over  as  a  morbid  state ;  as  one 
of  all  time,  and  not  a  product  of  modern  life  or  of  American  condi- 
tions. It  is  marked  by  a  host  of  subjective  symptoms  and  a  very  few 
objective  phenomena,  all  more  or  less  variable,  and  most  of  them  incon- 
stant. As  a  rule,  all  forms  of  nervous  energy — psychic,  motor,  and 
organic — are  reduced,  so  that  fatigue  is  more  quickly  occasioned  than  in 
health.  There  is  less  endurance,  and  consequently  greater  irritability, 
which  most  shows  itself  in  the  mental  sphere.  The  whole  state  is 
summed  up  in  the  classical  term  "  irritable  weakness." 

Etiology. — Neurasthenia  seldom  occurs  before  twenty  years  of  age 
or  after  fifty.  It  is  essentially  a  disorder  of  the  energetic,  productive, 
troubled  period  of  life.  Both  sexes  suffer,  and  perhaps  in  equal 
proportion,  but  in  females  a  more  common  association  with  hysteria 
frequently  carries  these  cases  into  that  list.  In  this  country  the  high 
altitudes  of  the  Western  plateaus  and  the  extremes  of  climatic  conditions 
in  the  Northern,  and  particularly  the  Northwestern,  States  apparently 
account  for  the  greater  frequency  of  neurasthenia  in  these  localities  than 
on  the  seaboard  and  in  the  Southern  States.  All  races  present  the  dis- 
order. Hebrews  and  Slavs  are  said  to  be  very  subject  to  it,  and  Scan- 
dinavians,  at  least   in   this    country,  furnish  a    large    contingent.      A 


564  NEUROSES. 

neuropathic  heredity  is  less  common  than  in  hysteria  or  epilepsy,  but  neu- 
rasthenics are  very  commonly  found  at  the  head  of  a  neuropathic  strain. 
Debilitating  conditions  in  the  antecedents  of  neurasthenics  are  very 
common.  Gout,  rheumatism,  tuberculosis,  syphilis,  excesses,  dissipa- 
tion, malaria,  and  all  the  cachexias  in  parents  are  likely  to  discount  the 
stamina  of  offspring  and  favor  the  early  limitation  of  endurance  and 
vigor  demonstrated  in  neurasthenia.  A  defective  education  that  omits 
discipline  and  the  cultivation  of  self-control,  poorly  fitting  the  child  for 
the  rude  shocks  of  later  life,  may  be  a  predisposing  cause.  Educational 
methods  that  overtrain  and  overstrain  may  directly  induce  the  neurosis. 
Occupations  of  all  varieties  furnish  neurasthenics.  It  is  only  requisite 
that  the  element  of  overwork  come  in,  whether  the  labor  be  mental  or 
physical.  Overwork,  moreov^er,  is  a  variable  quantity,  relative  to  the 
forces  and  endowments  of  the  individual. 

Among  the  inciting  causes  overwork  is  the  most  common,  and  asso- 
ciated with  it  we  usually  encounter  anxiety,  worry,  or  excitement,  which 
depress  the  patient's  forces,  often  at  the  same  time  impelling  him  to 
greater  efforts.  The  business  man,  anxious  for  his  ventures,  works 
doubly  hard  to  secure  success.  The  sleepless  mother,  worn  with  care 
and  nursing,  does  double  and  treble  duty,  and  finally  "  goes  to  pieces  " 
when  the  strain  is  over.  The  overtrained  athlete  goes  "  stale." 
Excesses,  by  their  debilitating  effects,  are  frequent  sources  of  neurasthenia. 
Alcohol,  tobacco,  venery,  masturbation,  either  as  onanism  or  withdrawal, 
unnatural  stimulation  of  sexual  responses,  and,  very  rarely,  sexual  con- 
tinence may  result  in  the  general  depression  we  call  neurasthenia. 
Trauma,  both  physical  and  mental,  may  induce  neurasthenia,  and  is 
likely  to  do  so  in  proportion  as  the  psychic  shock  is  well  developed. 
Kail  way  accidents  may  breed  neurasthenia  in  those  who  do  not  receive 
a  scratch.  The  fright  is  often  worse  than  the  blow.  Together  they 
may  cause  a  double  injury.  A  muscular  strain  from  overexertion,  as 
in  lifting,  may  start  neurasthenia,  particularly  if  the  back  be  hurt  and 
there  is  suggestion  or  fear  of  serious  harm  having  been  done.  The  more 
neurasthenia  is  studied,  the  more  prominent  will  its  mental  side  become. 
Exhausting  illness,  either  from  acute  or  chronic  disease,  may  cause 
neurasthenia.  Various  toxic  states,  such  as  lithemia  and  syphilis,  are 
prone  to  produce  it.  It  is  usually  difficult,  and  often  impossible,  to 
determine  the  exact  cause  of  neurasthenia  in  a  given  case.  Ordinarily, 
there  are  a  number  of  both  predisposing  and  exciting  causes.  In  a 
large  number  of  instances  neurasthenia  is  secondary  to  and  symptomatic 
of  organic  conditions,  such  as  phthisis,  Bright's  disease,  diabetes,  gout, 
rheumatism,  uremic  and  toxic  states  generally. 

Pathology. — Although  we  know  no  pathological  anatomy  of  the 
disorder,  its  manifestations  are  those  best  explained  by  a  diminished 
dynamic  energy  and  lessened  recuperative  power  in  the  cerebrospinal 
axis,  and  especially  in  its  cellular  elements.  This  may  be  a  nutritional 
defect.  The  very  constant  factor  of  ])ersistent  overwork,  overstrain, 
and  overfatigue  in  the  causation  of  neurasthenia,  cou])led  with  Hodge's 
findings  in  the  motor  cells  after  an  expenditure  of  energy,  leads  to 
the  opinion  that  we   have  to  do  with   a   fatigue  neurosis,  general  in 


NEURASTHENIA.  565 

distribution  and  comparatively  slight  in  degree.  With  this  view  in 
mind,  we  will  be  the  better  able  to  understand  the  symptomatology  and 
the  requirements  for  treatment. 

Symptoms. — The  symptoms  of  neurasthenia  are  extremely  numer- 
ous. >Sonie  of  these  are  essential,  most  are  adventitious.  Charcot  con- 
sidered headache,  backache,  gastro-intestinal  atony,  neuromuscular  weak- 
ness, cerebral  depression,  mental  irritability,  and  insomnia  as  the  funda- 
mental symptoms  of  tiie  disorder, — the  true  stigmata  of  the  neurosis. 
Secondarily  and  inconstantly  arise  a  host  of  complaints  that  are  of  less 
importance  and  significance.  It  will  be  necessary  to  take  up  the  symp- 
toms seriatim.  It  may  be  said  of  them  all  that  they  indicate  a  deficiency 
of  function,  never  an  absolute  w^ant  of  it.  The  reduction  is  one  of 
quantity  rather  than  of  quality,  but  is  never  absolute  in  degree. 

Motor  Disorders. — A  constant  condition  in  neurasthenia  is  muscidar 
weakness.  The  patients  complain  that  muscular  eiforts  are  promptly 
fatiguing.  They  can  only  walk  a  few  squares,  standing  a  long  time  is 
exhausting,  and  exercise  or  use  of  the  back  and  upper  extremities  pros- 
trates them.  They  often  show  a  remarkable  diminution  of  strength  as 
registered  on  the  hand-dynamometer  or  in  lifting,  but  occasionally  a 
patient  can  put  forth  one  or  two  fairly  forcible  efforts,  and  then  the 
strength  quickly  subsides.  Sustained  effort  is  impossible.  As  another 
manifestation  of  the  generalized  myasthenia,  tremor  is  frequently  observed, 
and  can  usually  be  provoked  by  comparatively  slight  muscular  efforts. 
Lamarcqi  found  it  in  eighty-five  per  cent,  of  neurasthenics.  Many 
patients  complain  of  their  trembling  knees  and  shaking  hands,  or  the 
tremor  may  appear  in  the  handwriting,  especially  tow^ard  the  end  of  a 
long  letter,  where  the  firmness  of  the  strokes  is  also  likely  to  be  reduced. 
Tremor  in  the  lips  and  face  is  sometimes  noticed.  Muscular  twitching.^ 
in  the  face  and  extremities  are  not  rare.  The  tendon  7'eflexes,  ordinarily^ 
are  increased.  This  is  customarily  the  case  with  the  knee-jerk.  A 
tendency  to  widely  distributed  responses  is  frequently  present,  so  that  a 
tap  on  the  patellar  tendon  causes  starting  of  both  low^er  limbs  or  of  all 
four  extremities,  and  sometimes  gives  rise  to  a  complaint  of  pain  in  the 
back.  If  the  knee-jerk  be  repeatedly  produced,  the  intensified  re- 
sponse first  elicited  may  gradually  subside  and  even  disappear,  giving 
another  evidence  of  the  early  fatigue  of  the  nervous  apparatus.  In 
some  instances  a  tap  on  muscle  or  nerve-trunk  will  call  forth  a  similar 
response.  Ankle-clonus  is  sometimes  present,  but  is  spurious  in  char- 
acter, and  only  a  few  vibrations  of  the  foot  can  be  elicited.  Repetitions 
of  the  test  may  fail  to  produce  it.  Paralysis  or  abolished  knee-jerks 
are  not  found  in  neurasthenia  unless  due  to  other  coincidental  disease. 

Sensory  Disturbances. — Neurasthenia  never  causes  anesthesia. 
When  this  is  present  w^e  have  a  condition  of  actual  deficit,  to  wdiich  limit 
neurasthenia  does  not  go.  The  vague  subjective  disturbances  of  sensa- 
tion, on  the  other  hand,  are  limitless.  Among  them  a  feeling  of  general 
tiredness  and  fatigue  is  almost  constant,  and  the  recumbent  posture 
tends  to  become  habitual. 

1  "Revue  Neurol.,"  August  15,  1896. 


566  NEUROSES. 

Headache  is  one  of  tlie  most  common  symptoms ;  it  is  practically 
never  wanting  and  often  is  described  in  striking  terms.  In  some 
instances  it  is  slight  and  constant,  more  often  it  is  produced  l>y  any 
muscular  or  mental  eifort,  and  occasioned  by  any  disturbing  emotion. 
Usually  it  is  occipital,  "  at  the  base  of  the  brain,"  as  these  patients  are 
fond  of  saying;  but  it  may  be  frontal,  temporal,  or  vertical.  One 
describes  a  sensation  as  if  the  head  were  splitting  or  the  skull  lifting ; 
another  has  a  terrible  weight  or  a  severe  constriction  about  the 
head.  This  lead-cap  headache  is  very  common.  Heaviness,  throbbing, 
buzzing,  a  sensation  of  wind  blowing  or  of  water  running  under  the  scalp, 
and  many  others  are  perhaps  indicative  of  the  vasomotor  disturbances 
within  the  skull.  Backache  is  equally  common  with  headache.  It  is 
probably  a  fatigue  symptom  for  the  most  part,  though  sometimes 
referable  to  gastro-intestinal  disturbances.  The  small  of  the  back  is  its 
usual  seat,  whence  it  streaks  up  between  the  shoulders  or  through  the 
loins  and  down  the  limbs.  Very  commonly  it  is  associated  with  a 
*'  drawing  "  sensation  at  the  back  of  the  neck,  and  the  occipital  pain  is 
then  usually  complained  of.  By  lying  down  or  by  padding  a  chair 
with  pillows,  some  relief  is  obtained.  The  advanced  case  customarily 
assumes  one  of  these  expedients.  In  milder  cases  the  backache  is 
occasioned  by  any  eifort  or  disturbing  circumstances  and  subsides  upon' 
rest. 

Tenderness  is  usually  found  over  the  spine  and  is  rather  superficial 
in  character,  but  occasionally  is  intensified  by  deep  pressure.  Rarely 
the  spine  is  tender  its  entire  length ;  usually  only  small  sensitive  spots 
are  present.  The  upper  cervical  spine  near  the  occiput,  over  the 
vertebra  prominens,  opposite  the  lower  angle  of  the  scapula,  at  the  waist- 
line, at  the  top  of  the  sacrum,  and  over  the  coccyx  are  the  favorite 
locations.  Sometimes  the  tenderness  is  diffuse  and  the  skin  over  the 
entire  dorsum  is  painfully  over-sensitive.  Sometimes  this  sensitiveness 
prevents  the  dorsal  decubitus  or  interferes  with  sitting  up.  It  is  likely 
to  be  aggravated  by  anything  which  disturbs  the  patient  or  increases 
the  other  symptoms.  Sensitiveness  on  the  head,  limbs,  or  other  por- 
tions of  the  trunk  is  not  rare,  and  is.  usually  associated  with  spontaneous 
pain  in  the  same  location.  The  outlines  of  these  sensitive  areas  are 
never  sharply  defined,  and  they  may  shift  position  or  vary  in  intensity 
within  a  few  hours  or  days,  but  sometimes  remain  practically  stationary 
for  months. 

All  manner  of  vague  sensations  of  heat,  cold,  prickling,  tightness, 
numbness,  stiffness,  weakness,  fatigue,  soreness,  pain,  pressure,  etc., 
referred  to  this  or  that  part  of  the  l:)ody  or  limits  are  constantly  encoun- 
tered. In  addition  there  are  a  host  of  abnormal  feelings  referred  to  the 
thoracic,  abdominal,  pelvic,  and  generative  organs. 

Visual  Disturbances. — The  neurasthenic  commonly  complains  that 
reading  has  grown  difficult  because  it  causes  headache  and  vague 
distress,  and  states  that  the  letters  blur  or  run  together  after  a  few 
minutes.  In  other  instances  they  can  not  maintain  attention.  Careful 
examination  will  usually  demonstrate  that  the  accommodative  apparatus 
and  the  retinal  sensitiveness  are  promptly  fatigued.    One  is  a  motor  loss,  the 


NEURASTHENIA.  567 

other  a  sensory  deficiency.  The  first  is  shown  by  the  rapidly  diniinisli- 
ing  ability  to  clearly  make  out  the  test-type ;  the  second,  by  the  quickly 
narrowing  visual  field,  due  to  impaired  sensitiveness  in  the  retinal 
periphery.  Both  may  be  regained  after  a  slight  rest.  A  high  and 
oscillating  degree  of  muscular  asthenopia  is  usually  due  to  neurasthenia, 
and  commonly  subsides  as  the  nervous  state  improves.  Deficiency  of 
the  inter ui  is  the  usual  finding. 

Photophobia  may  be  encountered  of  sufficient  intensity  to  keep 
patients  in  dark  rooms  or  wearing  colored  glasses.  In  lessened  degree 
retinal  hyperesthesia  is  not  uncommon,  and  is  similar  to  the  cutaneous 
sensitiveness.  Misty  obscurities  and  a  veiling  of  vision  are  sometimes 
described,  or  everything  looks  strange  and  unreal.  The  pupils  are 
usually  very  mobile,  contracting  and  expanding  excessively,  sometimes 
sluggishly,  sometimes  very  actively  and  even  independently  of  light  or 
accommodative  efforts.  Inequalities,  both  transient  and  persistent  for 
days,  are  rarely  encountered.  Permanent  inequality  is  due  to  organic 
disease. 

Disorders  of  Hearing-,  Smell,  and  Taste. — Hearing  is  apparently 
frequently  disordered.  Thus,  patients  start  at  the  slightest  sound,  and 
often  tie  up  the  door-bell  and  seek  seclusion  to  avoid  all  such  irritation. 
This  is  as  much  mental  as  aural,  perhaps,  but  tinnitus  in  various  forms 
and  throbbings  in  the  ears  are  due  to  the  irritable  weakness  that  spares 
no  nerve.  Complaints  of  peculiar  or  bad  smells  and  tastes  have  a 
similar  significance. 

Gastro-intestinal  Disorders. — Nervous  indigestion  is  one  of  the 
commonest  features  of  neurasthenia.  The  appetite  is  often  capricious, 
and  may  be  excessive  or  greatly  diminished.  The  mere  thought  of 
food  may  be  repugnant.  In  milder  cases  there  are  complaints  of  the 
food  lying  heavy  or  of  gaseous  eructations,  which  may  or  may  not  be 
attended  by  heart-burn.  The  gaseous  gastric  distention  may  suggest 
dilatation,  and  often  provokes  cardiac  palpitation  and  precordial  and 
epigastric  distress.  In  more  aggravated  cases  dilatation  actually  occurs, 
and  hydrochloric  acid  may  disappear  from  the  gastric  secretion.  Di- 
gestion is  retarded  and  deficient,  but  the  tongue  may  remain  clean  and 
nutrition  still  l)e  inadequate  to  maintain  the  body- weight.  The  small  in- 
testine is  usually  affected  in  the  same  atonic  fashion,  causing  constipation. 
In  the  severe  cases  of  neurasthenia  all  these  conditions  are  aggravated. 
The  eructations  of  gas  become  frequent,  noisy,  and  distressing  ;  meteor- 
ismus,  colicky  pains,  alternating  constipation  and  mucous  diarrhea,  intes- 
tinal fermentation,  and  the  passage  of  undigested  food  mark  the  atonic 
and  irritable  state  of  the  gastro-intestinal  tract.  Cases  present  great 
variations,  and  the  same  case  is  rarely  consistent  in  regard  to  these 
features. 

Circulatory  Disorders. — Cardiac  palpitation  due  to  digestive  dis- 
turbance is  one  of  the  common  symptoms  in  neurasthenia,  but  may 
result  from  other  causes,  as  muscular  or  mental  efforts,  sudden  starts  or 
embarrassments  of  any  sort.  In  some  instances  it  reaches  a  high  degree 
and  is  attended  by  precordial  pain,  a  tumultuous  heart's  action,  throb- 
bing arteries,  and  generalized  distress.      In  other  cases  it  may  occasion 


668  NEUROSES. 

a  pseudo-angina  pectoris  that  mimics  a  stenocardial  attack  very  closely. 
A  small,  rapid  puke  of  about  90  a  minute  is  commonly  present  in  neu- 
rasthenia, and  in  attacks  of  palpitation  it  may  reach  140  or  160.  The 
rate  is  promptly  increased  in  all  cases  by  any  distressing,  exacting,  or 
disturbing  cause.  Hemic  murmurs  are  not  rare  in  advanced  cases, 
when  the  general  nutrition  has  been  reduced.  The  feebleness  of  the  cir- 
culation is  shown  by  the  cold  extremities  commonly  encountered.  Vaso- 
motor dorms  in  neurasthenia  are  the  rule.  Localized  or  general  flush- 
ings, sweats,  and  aortic  throbbing  may  greatly  annoy  the  patients. 

Secretory  Disorders. — The  urine  is  ordinarily  scant  and  high- 
colored.  Neurasthenics  drink  little  water,  and  the  irritating  urine  may 
cause  much  vesical  uneasiness  and  frequent  micturition.  There  is  com- 
monly an  increase  of  uric  acid  and  urates,  or  a  great  abundance  of 
phosphates  and  oxalates  may  be  noted,  and  the  urine  may  be  neutral  or 
alkaline  in  reaction.  All  fluid  secretions,  as  the  perspiration,  saliva, 
gastric,  intestinal,  and  synovial  fluids  may  be  deficient.  In  other  in- 
stances they  are  increased,  or  increase  and  deficiency  may  alternate. 
Some  patients  complain  that  the  slightest  effort  or  embarrassment  causes 
them  to  sweat  profusely,  usually  about  the  head  and  neck.  The  cold, 
clammy  hand  of  neurasthenia  is  rarely  wanting. 

Genital  Disorders. — The  average  male  neurasthenic  complains  of 
lessened  sexual  power.  If  unmarried,  nocturnal  emissions  frighten  him, 
and  he  is  convinced  that  he  has  spermatorrhea  by  the  cloudiness  of  his 
urine.  If,  perchance,  there  has  been  an  antecedent  habit  of  masturba- 
tion, every  symptom  is  warped  by  him  into  relation  with  the  supposed 
impotence,  and  he  develops  into  a  confirmed  sexual  neurasthenic  with- 
out erections  and  with  vague  paresthetic  sensations  or  actual  tenderness 
and  pains  in  the  genitals  that  claim  his  undivided,  brooding  attention. 
If  married,  premature  ejaculations  and  loss  of  sexual  appetite  in  milder 
cases  are  followed  by  actual  inability  in  the  severer  forms,  and  some 
sensory  hyperesthesia  or  lessened  sensitiveness  of  the  parts  may  be  found. 

In  women  analogous  symptoms  are  encountered,  but  much  less 
frequently.  Some  are  troubled  by  nocturnal  orgasms  accompanying 
dreams  from  which  they  awake  nervous,  depressed,  and  exhausted.  In 
married  women  sexual  appetite  may  at  first  be  somewhat  increased,  but 
quickly  diminishes  and  commonly  disappears,  not  seldom  being  followed 
by  an  actual  distaste  or  even  disgust.  Pelvic  pains  and  genital  insen- 
sitiveness,  or  hyperesthesia,  are  often  added,  and  further  serve  to  inhibit 
intercourse. 

Mental  Disturbances. — The  psychic  side  of  neurasthenia  is  an 
interesting  and  important  feature  of  the  neurosis.  All  the  mental  mani- 
festations of  the  neurasthenic  have  in  common  the  same  elements  wlpch 
dominate  the  physical  features — namely,  weakness  and  irritability.  The 
capacity  for  mental  ivork  is  abridged,  just  as  the  muscular  power  is 
reduced.  Protracted  mental  efforts  become  irksome  or  impossible,  and 
in  many  instances  attempts  to  read  or  think  or  converse  for  a  few 
minutes  produce  so  much  fatigue  and  discomfort  that  they  must  be 
discontinued.  This  mental  asthenia  also  shows  itself  in  the  reduction  of 
the  mental  concentration  necessary  for  fixing  and  maintaining  attention. 


NEURASTHENIA  '     569 

Neurasthenics  can  not  keep  their  minds  on  the  printed  page  nor  follow 
a  line  of  thought  for  any  great  length  of  time.  They  are  inattentive  to 
details,  and  consequently  do  not  clearly  apperceive  them.  Hence  arises 
the  almost  constant  complaint  of  a  Iosh  of  memory.  Active  spontaneous 
mentation,  wiiich  is  dependent  upon  mental  strength,  is  also  reduced. 
Ideas  do  not  occur  to  such  patients  with  their  usual  vigor  and  rapidity, 
and  they  often  assert  that  they  can  not  think.  Their  courage  naturally 
subsides  with  their  strength.  Attracted  by  the  cardiac  palpitation  or 
their  sexual  incapacity  or  their  mental  debility,  or  by  any  other  neuras- 
thenic index,  they  become  mtrospecfive,  and,  misconstruing  their  symp- 
toms, develop  a  lot  of  nosophobias.  As  the  suggestions  and  reminders 
of  these  fears  are  constantly  present,  the  neurasthenic  becomes  saturated 
with  them,  thus  still  further  reducing  the  power  of  attention  and  mem- 
ory. They  become  morbidly  self-watchful  and  tend  to  hypochondriacal 
depression.  In  some  instances  these  morbid  fears  pass  into  insane  delu- 
sions and  obsessions,  and  are  then  beyond  the  boundaries  of  neuras- 
thenia, but  the  dividing  line  is  decidedly  indefinite.  Indeed,  many 
psychoses  begin  as  a  neurasthenia  and  even  general  paresis  may  show  a 
neurasthenic  prodromal  period. 

Fear,  arising  easily  from  a  consciousness  of  weakness  and  a  loss  of 
courage,  often  becomes  associated  with  external  conditions  and  sugges- 
tions. An  attack  of  palpitation  in  a  crowded  place  may  induce  a 
condition  of  fear  or  apprehension  constantly  associated  with  like  con- 
ditions. Some  fear  to  be  alone,  others  to  be  in  open  or  in  narrow 
or  in  high  places.  Some  fear  darkness,  some  storms,  some  lightning, 
some  special  localities,  some  contamination  by  dirt  or  infection  by 
disease.  The  neurasthenic  always  recognizes  the  baselessness  of  such 
fears,  though  he  may  not  be  able  to  dispel  them  ;  the  insane  hypo- 
chondriac accepts  them  as  actual  necessary  facts,  and  can  not  be  per- 
suaded to  the  contrary. 

Frequently  the  neurasthenic  recognizes  a  diminished  affection  for  his 
family  or  others,  and  sometimes  is  greatly  troubled  by  it.  He  is 
irritable,  peevish,  fault-finding,  and  resentful.  The  business  man  dreads 
his  daily  tasks  and  dislikes  to  meet  new  customers  or  even  old  friends. 
The  emotions  are  less  stable,  and  there  is  ever  a  tendency  to  weakness  and 
depression.  Such  patients  are  lacrymose  on  slight  occasion  or  break 
down  in  telling  of  themselves  or  in  contemplating  their  darkened  future. 

Sleep  is  commonly  faulty  from  the  first.  Neurasthenics  habitually 
present  insomnia.  In  some  instances  there  is  a  difficulty  in  getting  to 
sleep  or  the  sleep  is  constantly  disturbed.  Exceptionally  the  sleep  is 
sound  and  prolonged,  but  the  patient  awakes  unrefreshed.  and  usually 
more  depressed  and  prostrate  than  upon  retiring.  Ordinarily,  the  sleep 
is  disturbed  by  troubled  dreams,  which  often  are  of  a  dreadful  or  night- 
marish character.  In  shock  or  traumatic  cases  the  accident  episode 
may  be  repeated  in  the  dreams  night  after  night  or  several  times  the 
same  night.  Charcot  laid  especial  stress  upon  such  formulated  dreaming 
in  neurasthenia. 

The  General  State. — In  neurasthenia  of  long  standing  the  general 
nutrition  is  commonly  defective,  and  high  degrees  of  anemia  and  ema- 


570  NEUROSES. 

ciation  may  be  encountered.  Neurastlienia  of  a  moderate  grade  of 
severity,  but  sufficient  to  disable  the  patient  for  ordinary  pursuits,  is 
consistent  with  fair  nutrition,  and  some  of  the  most  inveterate  cases 
may  become  quite  fat.  Emaciation,  on  the  one  hand,  is  not  a  hopeless 
indication,  nor,  on  the  other  hand,  does  plumpness  indicate  an  easily 
manageable  case. 

Forms. — In  view  of  the  multiplicity  of  symptoms  in  neurasthenia 
and  their  lack  of  uniformity  in  various  patients,  it  is  not  surprising  that 
numerous  forms  have  been  described.  The  terms  cerebral,  spinal,  and 
sexual  neurasthenia  have  been  used  to  designate  cases  in  which  symp- 
toms referable  respectively  to  the  head,  back,  and  genitals  have  pre- 
ponderated, but  it  is  best  to  look  upon  neurasthenia  as  one  and  indivisible. 
Adventitious  or  exaggerated  symptoms  may  variously  tone  the  clinical 
picture  in  different  cases,  but  neurasthenia  remains  a  generalized  disorder 
of  the  entire  nerve-apparatus.  In  the  foregoing  description  of  neuras- 
thenia the  simple  variety  has  been  constantly  in  view.  We  are  always 
to  have  in  mind  that  neurasthenia  may  be  symptomatic  of  some  organic 
.process  of  which  it  is  a  secondary  expression.  Thus,  it  may  follow 
all  forms  of  extraordinary  illness  or  injury,  spring  from  the  various 
cachexias,  and  succeed  all  toxic  and  infectious  processes.  All  such  condi- 
tions must  be  eliminated  before  we  may  call  a  case  one  of  simple  or  essen- 
tial neurasthenia.  Again,  neurasthenia  is  frequently  encountered  in  asso- 
ciation with  other  neuroses.  This  is  particularly  true  of  hysteria,  and 
it  is  sometimes  impossible  to  say  where  the  neurasthenia  ceases  and  the 
hysteria  begins.  For  such  cases  the  term  hysteroneurasthenia  has  been 
employed. 

Course. — Neurasthenia  is  essentially  a  chronic  malady.  Ordinarily, 
its  onset  is  insidious,  and  it  is  only  after  weeks  and  months  of  growing 
incompetency  and  laborious  efforts  to  carry  on  the  usual  duties  that  the 
patient  recognizes  something  wrong  and  seeks  medical  advice.  In  the 
traumatic  form  of  neurasthenia  the  neurosis  may  be  quickly  established, 
but  it  is  not  uncommon  for  the  patient  to  go  about  as  usual  for  several 
days  or  weeks  after  the  accident  or  injury,  and  gradually  develop  the 
nervousness,  weakness,  and  prostration.  Once  established,  neurasthenia 
tends  to  persist  indefinitely,  and  only  some  radical  change  in  the  mode 
of  life,  serving  to  relieve  the  patient  of  worry  and  work,  is  likely  to  favor- 
ably modify  the  condition.  Frequently  remissions  are  presented,  but 
the  patient  relapses  under  any  unusual  demands,  and  slowly  or  partially 
regains  the  former  status.  Even  after  long  periods  of  improvement 
there  is  a  tendency  to  ready  recurrence  under  the  influence  of  any  excit- 
ing cause. 

Diagnosis. — The  diagnosis  of  neurasthenia  is  usually  easy.  The 
combination  of  mental  and  physical  weakness  and  irrital^ility  willi 
gastro-intestinal  atony,  backache,  headache,  insomnia,  and  rapidly  ex- 
hausted retinal  sensitiveness,  justifies  the  diagnosis.  The  difficulty  mainly 
lies  in  overlooking  some  basic  organic  disease.  One  should  never  be 
content  with  a  diagnosis  of  neurasthenia  until  he  can  thoroughly  satisfy 
himself  that  he  is  not  confronting  a  symptomatic  form  of  the  neurosis. 
Hysteria  may  be  associated  with  neurasthenia,  but  has  its  own  stigmata. 


NEUB'ASTHENIA.  '     571 

It  is  to  be  kept  in  mind  that  disturbances  of  function  in  neurasthenia 
are  those  of  irritable  weakness  and  not  of  actual  loss.  Anesthesias,  pal- 
sies, convulsions,  complete  loss  of  self-control,  actual  amnesias,  are  not 
the  property  of  neurasthenia,  but  are  the  ear-marks  of  hysteria.  True 
hji><)ch(m<h-iaxl^  is  a  variety  of  melancholia  with  actual  insane  delusions 
regarding  bodily  states.  In  neurasthenia  the  phobias  are  under  at  least 
partial  control,  and  sometimes  can  be  completely  relieved  by  a  reasonable 
statement  of  the  facts.  As  before  stated,  all  the  changes  of  function  in 
neurasthenia  are  in  the  nature  of  quantitative  reduction. 

Prognosis. — The  outlook  in  neurasthenia  is  commonly  good  if  the 
proper  treatment  can  be  instituted  and  maintained.  It  is  often  very  diffi- 
cult to  secure  the  co5peration  of  the  patient,  or  his  circumstances  may 
be  such  as  to  preclude  the  protracted  rest  and  change  usually  required 
to  restore  him.  In  that  event  he  worries  along  as  best  he  can,  possibly 
picking  up  some  drug  or  stimulant  habit,  and  may  recover  after  many 
months,  but  is  more  likely  to  break  down  completely  and  become  a 
confirmed  nervous  invalid.  If  of  a  psychopathic  stock,  some  pronounced 
mental  change  may  appear.  Cases  occurring  before  twenty  years  of  age 
are  likely  to  yield  readily  and  to  relapse  frequently.  Such  early  demon- 
stration of  insufficient  stamina  naturally  indicates  an  unstable  organi- 
zation. After  forty  the  prognosis  is  also  less  hopeful,  as  the  neuras- 
thenic exhaustion  occurs  in  tissues  that  have  largely  lost  their  resiliency 
and  recuperative  powers.  After  this  age  full  vigor  is  practically  never 
regained  if  the  neurasthenic  state  has  been  severe.  A  neuropathic  or 
psychopathic  heredity  or  evidence  of  degeneracy  in  the  patient  reduces 
the  chances  for  a  full  and  permanent  recovery.  The  bodily  condition  is 
of  less  significance  if  organic  disease  is  absent.  Cases  of  extreme  emacia- 
tion often  respond  admirably  to  treatment,  while  some  of  the  cases 
Avithout  marked  disturbance  of  bodily  function  are  inveterate. 

Treatment. — The  keynote  of  treatment  in  neurasthenia  is  rest. 
Depending  upon  the  severity  of  the  case,  upon  the  temperamental  char- 
acteristics of  the  patient,  and  upon  the  sex,  this  rest  may  be  partial  or 
as  complete  as  we  can  possibly  make  it.  In  the  milder  cases,  especially 
those  occurring  from  overwork  in  sedentary  pursuits,  in  patients  between 
the  ages  of  twenty  and  forty,  and  when  the  patient's  make-up  is  based 
upon  a  good  heredity,  the  full  Wier  Mitchell  rest  treatment  is  commonly 
not  required.  It  may  only  be  necessary  to  have  the  patients  spend  four 
or  six  additional  hours  in  bed  daily.  This  can  be  secured  by  having 
tliem  retire  shortly  after  the  evening  meal,  and  not  rise  until  late  in 
the  morning:.  A  hot  bath  of  five  minutes'  duration  and  a  glass  of 
hot  milk  or  a  glass  of  beer  on  retiring  for  the  night  encourage  sleep. 
A  cold  douche  or  cold  sponge,  to  the  full  length  of  the  spine  on  rising, 
gives  a  vigorous  morning  start.  In  addition,  an  hour's  rest  in  the 
recumbent  posture  in  the  middle  of  the  day  should  be  enjoined. 
The  amount  of  wovh  must  be  reduced.  It  is  rare  that  this  can  not  be 
done  even  in  the  most  responsible  positions.  It  should  be  needless  to  say 
that  the  condition  of  orc/anie  activity,  if  deranged,  must  be  put  to  rights. 
Constipation,  a  sluggish  skin,  or  inactive  kidneys,  if  uncontrolled,  will 
defeat    the    best   general    management.      Large  quantities  of  drinking 


572  NEUROSES. 

water  usually  aid  in  several  ways,  and,  as  a  rule,  neurasthenics  shun 
water.  If  these  regulations  can  be  instituted  during  a  vacation,  espe- 
cially one  spent  among  new  scenes,  an  additional  advantage  is  gained. 

In  the  severer  male  cases  an  absolute  separation  from  business  and 
family  is  usually  required,  and  a  long  sea  voyage  with  a  pleasant  com- 
panion often  works  wonders.  As  a  rule,  the  more  outdoor  air  and 
recreation  that  does  not  entail  eifort,  the  better,  but  to  put  a  neurasthenic 
on  a  bicycle  or  on  long  walks  adds  fuel  to  the  flames.  A  carefully 
selected,  nourishing,  fattening,  unstimulating  diet  is  of  considerable  im- 
portance. If  the  scales  show  a  gain  of  a  few  pounds,  success  is  assured. 
Men,  unless  practically  bedridden,  do  not  respond  favorably  to  the 
Mitchell  rest-treatment.  The  enforced  idleness  and  confinement  to 
bed  is  rarely  tolerated  by  them  if  they  can  possibly  be  about. 

In  the  severe  female  cases,  and  sometimes  in  young  males  or  com- 
pletely prostrated  men,  we  must  have  recourse  to  the  full  rest  plan  laid 
down  by  Mitchell.  The  details  of  this  are  furnished  in  all  modern 
works  on  therapeutics  and  need  not  be  repeated  here.  By  this  plan  ex- 
penditure of  energy  is  reduced  to  a  minimum,  strength  is  conserved  and 
increased  by  the  massage  and  electricity,  and  flesh  is  rapidly  made  by 
the  constant  feeding.  There  are  several  essentials  in  carrying  out  this 
procedure,  and  their  neglect  means  failure.  The  first  is  isolation  from 
relatives  and  friends,  and  the  establishment  of  an  entirely  new  and  hope- 
ful atmosphere.  In  some  instances  the  slightest  infraction  of  this  rule 
causes  immediate  relapse.  Equally  important  is  it  to  have  an  experi- 
enced and  tactful  nurse. 

Any  amount  of  general  hospital  training  does  not  make  a  good  nurse 
for  this  class  of  patients  or  furnish  the  endless  tact  and  self-repression 
needed  to  manage  them.  It  is  difficult  to  induce  nurses,  accustomed  to 
grave  operative  cases  and  severe  physical  illness,  to  appreciate  that  the 
endless  complaints  and  fault-findings  of  neurasthenic  patients  are  symp- 
tomatic of  their  state  and  not  merely  petulant  crankiness.  It  is  also 
very  important  that  the  treatment  take  place  in  a  suitable  location,  free 
from  disturbing  noises.  The  room  and  immediate  surroundings  of  the 
patient  must  be  bright  and  cheerful.  If  isolation  with  a  suitable  nurse, 
preferably  one  able  to  give  massage,  can  be  had,  the  other  details  of 
treatment  are  less  important.  The  absolute  milk  diet  does  well  in  some 
cases,  and  is  indispensable  in  a  few  at  the  begimiing,  but  if  food  is 
digested  and  the  bowels  active  it  is  immaterial  what  the  patient  eats  so 
long  as  it  is  nourishing,  abundant,  and  administered  at  frequent  inter- 
vals. Sleep,  usually  disturbed,  under  the  massage  and  forced  feeding 
soon  becomes  sound  and  prolonged.  Hot  milk,  an  alcohol  rub,  or  a 
glass  of  beer  at  bedtime  is  commonly  a  sufficient  hypnotic. 

No  scheme  of  treatment  in  neurasthenia  is  complete  that  ignores  the 
mental  elemeiit  of  the  disorder.  These  patients  are  frequently  impression- 
able, and  particularly  so  as  regards  their  own  health  and  prospects. 
Their  fears  can  not  be  laughed  to  scorn.  They  should  be  carefully  esti- 
mated, fully  explained,  and  then  dismissed.  It  is  not  advisable  to  allow 
these  patients  to  reiterate  their  complaints  to  the  physician  and  the 
nurse,  and  the  family  must  be  instructed  to  refuse  to  hear  pr  dis- 


NEURASTHENIA.  '   573 

CUSS  them  with  the  patient.  Ericouraginy  suggestions  and  hopeful  as- 
surances constantly  repeated  have  the  force  of  hypnotic  suggestion,  and  a 
very  real  therapeutic  value.  For  this  reason  the  physician  must  usually 
see  his  patient  frequently.  In  this  way  the  daily  use  of  static  electricity, 
hypodermic  injections  of  strychnin  or  water,  or  any  other  objective  ex- 
cuse, impresses  the  patient  and  permits  and  emphasizes  the  repeated  en- 
couraging suggestions. 

Thus  far  nothing  has  been  said  about  drugs,  and  there  is  very  little  to 
say.  Iron  and  arsenic  against  the  anemia,  trional  and  bromid  for  the 
insomnia,  laxatives  for  constipation,  may  be  given.  Strychnin  in  large 
doses,  or  bromids  and  sedatives  in  large  doses,  are  ill-advised  and 
commonly  harmful.  The  indications  are  to  rest  and  to  nourish,  not  to 
stimulate  or  to  depress.  Hydrotherapeutics,  especially  if  carried  on  at  a 
distance  from  home,  yield  good  results  in  mild  cases.  It  may  be  said 
that  the  treatment  of  neurasthenia  requires  judgment,  tact,  perseverance, 
and  personal  force  of  the  highest  order.  Wlien  the  neurosis  is  secondary 
to  organic  processes,  its  treatment  is  similarly  second  in  order.  Climatic 
conditions  embracing  windy  low-lying  stretches,  altitudes  above  3000 
feet,  and  fluctuating  extremes  of  temperature  are  decidedly  disadvan- 
tageous. As  a  rule,  neurasthenics  do  best  at  the  sea-level  and  preferably 
at  the  seaside. 


574  NEUROSES. 


.CHAPTER   VI. 
HYSTERIA. 

Hysteria  has  been  an  interesting  problem  since  the  earliest  days 
of  medical  thought.  Unrecognized  it  occasioned  the  demoniacal  "  pos- 
sessions" of  the  middle  ages,  and  furnished  some  of  the  martyrs  of 
Avitchcraft  and  religious  fanaticism.  Aifecting  whole  communities,  it 
caused  epidemics,  allayed  by  appeals  to  St.  Guy,  St.  Vitus,  or  other 
tutelary.  It  has  been  seen  in  the  excited  religious  gatherings  of  all 
countries.  As  a  disease  it  was  long  supposed  to  be  limited  to  the  female 
sex,  and  Avas"  attributed  to  vapors  or  other  influences  arising  from  the 
AA'omb  ;  hence  the  name  hysteria.  Only  in  recent  years  have  the  en- 
demic and  epidemic  forms  been  understood,  and  the  male  found  to  share 
AAdth  the  female  in  the  liability  to  the  psychoneurosis.  For  many  years 
the  mental  element  in  hysteria  has  been  at  least  partially  recognized. 
Moebius  used  the  definition,  "A  state  in  AAdiich  ideas  control  the  body 
and  produce  morbid  changes  in  its  functions."  So  far  as  the  paralyses 
and  contractures  are  concerned,  English  AAriters  liaA^e  described  them  as 
"  depending  upon  idea."  The  studies  of  Charcot  and  his  students  have 
placed  hysteria  upon  a  firm  clinical  basis,  and  enabled  nearly  all  of  its 
manifestations  to  be  traced  to  disturbances  in  the  psychic  sphere  or  in  its 
substrata.  Janet  says:  ''Hysteria  belongs  to  a  group  of  mental  dis- 
eases of  cerebral  insufficiency ;  it  is  especially  characterized  by  moral 
symptoms ;  the  principal  one  is  a  AA^eakening  of  the  faculty  of  psycho- 
logical synthesis."  "  It  results,"  adds  Dutil,  "  that  a  certain  number 
of  elementary  phenomena,  sensations,  and  images  are  not  preserved, 
and  appear  to  be  repressed  in  the  realm  of  consciousness."  In  addition, 
there  are  a  number  of  organic  phenomena — disturbances  of  nutrition, 
trophic  and  A^asomotor  disorders — of  a  neurotic  character.  Hence,  we 
class  hysteria  as  a  psychoneurosis. 

Etiology. — Hysteria  in  slight  or  severe  form  is  one  of  the  most 
common  of  nervous  diseases.  The  age  of  puberty  and  the  years  of 
adolescence  immediately  following  furnish  the  majority  of  cases.  After 
twenty-five  the  frequency  of  hysteria  declines  and  it  becomes  rare  after 
forty-five.  Before  ten  it  is  also  uncommon,  but  children  may  develop  it 
in  A^ery  marked  form  even  as  early  as  tAvo  or  three  years  of  age.  Formerly 
considered  almost  exclusiA^ely  limited  to  the  female  sex,  later  statistics 
go  to  shoAV  that  males  and  females  are  affected  Avith  hysteria  in  nearly 
equal  ratio.  According  to  Marie,  in  the  loAver  social  IcA^els  males 
predominate  ;  in  the  AA^ealthier  classes  females  are  more  commonly 
affected.  Hysteria  is  a  disease  of  all  countries  and  all  j-aces,  but  the 
Latin,   Slav^   and   Israelite  may  be  considered  as  particularly   liable. 


HYSTERIA.  "575 

Heredity  plays  an  important  ])ai-t.  Hysterics  usually  belong  to  neuro- 
pathic families.  Hysteria  in  the  mother  is  very  frequently  followed  by 
hysteria  in  the  daughter.  More  commonly,  however,  the  transmission 
is  by  transformation  from,  or  to,  other  neuroses  and  psychoses.  Arthrit- 
ism  or  phthisis  in  the  antece<.lents  of  hysterics  plays  the  same  part  as  in 
other  manifestations  of  degeneracy. 

Inciting-  Causes. — Emotional  disturbance  of  any  sort  may  initiate 
hysteria.  Fright,  grief,  worry,  chagrin,  and  every  sort  of  mental  and 
moral  strain  and  shock  are  the  common  starting-jioints  of  this  multiform 
disease.  TraHmatism  furnishes  a  large  quota  of  hysterics,  especially  of 
the  male  sex,  owing  to  their  greater  liability  to  such  accidents.  In  all 
such  circumstances,  unless  consciousness  be  abolished  instantly  without 
preceding  anxiety  or  fright,  the  attending  psychic  states  must  be  taken 
into  consideration.  As  a  practical  fact,  the  likelihood  of  hysteria  fol- 
lowing trauma  is  in  direct  proportion  to  the  intensity  of  the  mental 
shock.  The  physical  injury  may  be  insignificant.  Lightning-stroke, 
surgical  wounds,  and  internal  conditions,  such  as  gastric  ulcers,  nephritic 
and  hepatic  colics,  may  act  as  causes. 

Intoxication  by  lead,  mercury,  sulphid  of  carbon,  oxid  of  carbon, 
tobacco,  morphin,  cocain,  and  chronic  alcoholism,  or  even  a  single 
alcoholic  debauch,  may  induce  hysteria.  In  many  such  cases  these 
intoxications  furnish  a  basis  on  which  hysteria  develops  by  the  inci- 
dental action  of  some  other  provocation.  Infectious  diseases,  such  as 
typhoid,  diphtheria,  influenzra,  pneumonia,  scarlatina,  malaria,  and  syph- 
ilis, may  provoke  hysteria.  It  may  occur  in  cachectic  states  due  to 
chlorosis,  diabetes,  phthisis,  and  cancer.  It  is  found  as  an  associate  of 
all  organic  diseases  of  the  brain  and  spinal  cord,  frequently  appearing 
in  tabes,  syringomyelia,  and  insular  sclerosis.  Either  mental  or  physical 
overwork  may  cause  it.  Wherever  people  of  suitable  age  are  domiciled 
together,  hysteria  may  become  endemic  through  the  force  of  imitation 
and  suggestion  arising  from  an  initial  case  of  hysteria  or  of  some  phys- 
ical disease.  Schools,  prisons,  barracks,  and  large  families  may  thus  be- 
come affected.  Usually  in  such  instances  there  is  great  similarity  among 
the  cases.  In  this  country,  under  the  prolonged  excitement  and  fervor 
of  protracted  religious  meetings  in  rural  districts,  endemics  of  hysterical 
spasms  and  even  of  dancing,  in  all  respects  similar  to  the  medieval 
epidemic  dance  of  St.  Vitus,  have  developed.  Hysterical  patients  in 
hospitals  may  closely  mimic  all  the  symptoms  and  physical  disabilities 
of  other  patients  with  whom  they  are  kept  in  contact.  In  other  cases 
they  reproduce  the  manifestations  of  some  disease  with  which,  in  their 
past  experience,  they  have  been  made  familiar. 

Symptoms. — The  innumerable  symptoms  of  hysteria,  to  follow  the 
plan  of  the  French  writers,  may  be  divided  into  two  major  groups  : 
those  which  are  essentially  persistent, — the  stigmata  ;  and  those  which 
occur  incidentally,  are  intermittent  or  transitory, — the  accidents  of 
hysteria.  The  stigmata  are  not  necessarily  present  singly  or  in  com- 
bination, but,  once  developed,  tend  to  persist  so  long  as  the  affection 
lasts.  The  accidents  present  the  greatest  diversity  in  different  patients, 
but  usually,  if  they  occur  repeatedly,  tend  to  uniformity  in  a  given  case. 


576  NEUROSES. 


Further,  some  hysterical  accidents,  as  paralyses  or  contractures,  may 
be  of  long  duration,  and,  once  thoroughly  established,  have  the  force  of 
stigmata. 


STIGMATA  OF  HYSTERIA. 

The  stigmata  of  hysteria  are  sensory,  motor,  and  psychic. 

Sensory  Stigmata. — In  hysteria  the  sensory  disorders  are  (1)  of 
the  negative  variety, — anesthesias  ;  and  (2)  of  the  positive  sort, — hyper- 
esthesias. They  are  usually  both  represented  in  a  given  case,  but  the 
anesthesias  are  the  more  important  symptomatically. 

Hysterical  anesthesia  may  affect  sensation  in  all  its  modes  and 
tenses,  including  the  special  senses.  The  general  cutaneous  sensibility 
may  be  disaggregated  so  that  only  certain  elements  persist  and  a  limited 
group  of  stimuli  alone  serve  to  arouse  the  sensorium,  as  in  a  thermo- 
analgesia  that  parallels  the  sensory  dissociation  of  syringomyelia.  The 
diminution  of  sensibility  may  be  partial  or  complete,  and  often  varies  in 
the  same  patient  within  a  very  short  time.  Various  degrees  of  anesthesia 
may  likewise  be  found  in  different  regions,  and  the  anesthetic  area 
represents  remarkable  variations  of  extent  and  distribution  in  different 
cases,  and  also  in  the  same  case  at  different  times.  Some  form  and 
degree  of  anesthesia  is  rarely  lacking  in  hysteria  that  has  existed  any 
length  of  time,  and  often  it  is  developed  very  early.  It  is  obligatory 
to  persistently  search  for  it  in  every  instance,  but  care  must  be  exer- 
cised not  to  induce  it  by  suggestion.  As  a  rule,  hysterics  are  themselves 
ignorant  of  their  sensory  deficiencies.  The  anesthesia  may  be  (1)  super- 
ficial, affecting  mainly  the  skin  and  mucous  tissues,  or  (2)  it  may  involve 
the  deeper  structures. 

Cutaneous  anesthesia  may  be  absolute.  Pricking,  pinching,  hot  and 
cold  bodies,  produce  no  response.  Some  patients  are  merely  analgesic, 
and  this  is  the  common  defect.  Less  frequently  there  may  be  thermo- 
anesthesia or  thermo-analgesia,  and,  most  rarely  of  all,  tactile  sensations 
alone  may  be  wanting.  Very  exceptionally  the  hysterical  patient  feels 
the  faradic  current  in  the  anesthetic  area  or,  more  rarely  still,  presents 
an  area  insensitive  to  this  stimulus  alone.  Complete  anesthesia,  hypes- 
thesia,  and  analgesia  are  the  commonly  encountered  forms.  The  mucous 
membrane  within  the  range  of  examination  may  show  the  same  anesthetic 
modifications  of  sensibility.  The  buccal,  ])haryngeal,  laryngeal,  nasal, 
conjunctival,  anal,  urethral,  and  vaginal  surfaces  may  be  entirely  insen- 
sitive or  present  dissociation  of  sensation. 

The  deeper  parts  are  frequently  anesthetic.  Bones,  muscles,  ligaments, 
and  nerve-trunks  may  sometimes  be  pierced,  twisted,  wrenched,  and 
contused  without  giving  rise  to  distress  or  even  provoking  a  localized 
sensation  of  any  sort.  The  muscular  sense  for  a  limb  may  be  abolished 
so  that  with  bandaged  eyes  the  patient  has  no  knowledge  of  its  position, 
can  not  estimate  weights,  recognize  pressure,  or  feel  fatigue. 

The  Special  Senses. — Taste  and  smell  may  be  perverted,  dimin- 
ished, or  abolished.     Certain  sapid  articles  may  fail  to  arouse  the  sense 


HYSTERIA. 


'   oil 


of  taste,  while  others  are  still  detected.  The  loss  of  taste  is  usually 
limited  to  a  portion  of  the  tougue  and  nioutli.  Hearing  is  often  greatly 
diminished,  but  complete  hysterical  deafness  is  very  uncommon. 
Rinne's  test  (see  p.  64)  shows  the  disturbance  to  be  central.  When  the 
loss  of  hearing  is  pronounced,  one  commonly  finds  more  or  less  anes- 
thesia in  the  auditory  canal  and  on  the  same  side  of  the  head  and  face, 
but  absolute  anesthesia  of  the  drumhead  is  exceptional,  i 


Left. 


Fig.  246.— Hysterical  concentric  contraction  of  visual  field  of  right  eye ;  amaurosis  of  left  eye  (Tourette). 

In  hysteria  vision  is  very  frequently  modified,  and  some  of  the 
changes  in  this  special  sense  are  of  the  utmost  importance  for  diagnosis. 
Complete  blindness  is  very  rare,  usually  of  abrupt  onset,  a  fcAV  days' 
duration,  and  sudden  recovery,  but  vision  is  often  reduced  in  one  eye  to 
counting  fingers  or  less.  Of  greater  frequency  and  of  more  importance 
are  the  lesser  and  commonly  persistent  defects.  These  consist  of:  (1)  A 
reduction  of  the  field  ;  (2)  troubles  of  color  perception,  and  (3)  errors 
of  accommodation. 

Contraction  of  the  Visual  Field. — In  the  great  majority  of  hysterics 
the  visual  field  is  concentrically  contracted.  This  is  usually  found 
bilaterally,  but  commonly  more  on  one  side  than  the  other,  and  some- 
times only  on  one  side.  The  defect,  as  in  that  of  all  the  special  senses, 
when  unilateral  or  most  marked  on  one  side,  usually  corresponds  to  a 
unilateral  distribution  of  disturbed  cutaneous  sensibility,  but  the  opposite 
situation  may  be  encountered.  In  total  amblyopia  the  contraction  of 
the  field  reduces  it  to  zero.  In  a  given  case  the  retraction  of  the  field 
is  practically  permanent,  but  it  may  fluctuate  greatly.  An  epileptiform 
attack,  fatigue  of  the  eye,  emotions,  and  variations  of  attention  may 
modify  its  limits.  Hysterical  hemiopia  and  scotomata  are  so  infrequent 
that  they  should  always  suggest  an  organic  lesion. 

The   di/schromatopsia  is    more    characteristic   of  hysteria  than   the 

contracted  field,  which  is  also  present  in  neurasthenia.      In  the  normal 

eye  the  fields  for  the  various  elementary  colors  are  not  coextensive  (see 

p.  63).     In  their  natural  order  blue  has  the  largest  field,  followed  by 

1  Chavanne,  Paris,  1901,  "  Oreille  et  Hysterie." 

37 


578 


NEUROSES. 


yellow,  oraDge,  red,  green,  and  violet.  In  hysteria  not  only  are  the 
fields  for  form  and  light  perception  contracted,  but  those  for  colors  are 
also  diminished,  and  to  a  proportionate  degree.  The  important  particu- 
larity is  that  the  normal  order  is  generally  changed.  The  red  field  often 
exceeds  the  blue.  When  the  color-fields  are  extinguished,  they  usually 
disappear  in  this  order  :  violet,  green,  blue,  yellow,  and,  last  of  all,  red. 
Objects  are  then  finally  seen  as  grayish,  and  we  have  the  condition  of 
achromatopsia. 


Fig.  247.— Hysterical  bilateral  concentric  contraction  of  visual  fields  (Tourette). 


Fie  248.— Concentric  retraction  of  Tisual  fields  for  colors  usually  found  in  hysteria.    Red  field  inclosed 
thus:+  +  +;  white  field, ;  blue  field, ;  green  tield,  +-  +  -+  (Souques). 

Accommodative  errors  in  hysteria  are  sometimes  encountered,  by  which 
near  vision,  particularly,  is  rendered  faulty.  To  the  same  source  have 
been  attributed  the  monocular  diplopia,  polyopia,  macropsia,  and  micropsia 
that  are  occasionally  met.  In  this  condition,  with  the  opposite  eye  cov- 
ered, the  patient  fixes  the  gaze  upon  a  pencil  close  to  the  eye.  As  it  is 
withdrawn,  its  image  doubles,  and  at  a  greater  distance  a  third  may  ap- 
pear, and  they  all  increase  in  size,  and  again  dimini.sh  as  the  pencil  ap- 
proaches. Errors  of  curvature  in  the  cornea  must  be  excluded  to  render 
the  symptom  significant. 


HYSTERIA.  579 

It  has  recently  been  recognized  that,  aside  from  complete  bilateral 
blindness,  the  various  forms  of  hysterical  amblyopia  are  not  present  in 
binoeular  vision.  Even  opening  the  unaffected  eye,  in  the  case  of  uni- 
lateral amblyo})ia,  at  once  widens  the  contracted  field  (Parinaud). 
Patients  who  can  not  read  with  either  eye  alone  may  do  so  readily  with 
both.  That  the  aml)lyopic  eye  sees  is  easily  demonstrated.  A  red 
glass  over  the  affected  eye  and  a  prism  over  the  other  double  the  image 
of  a  flame,  and  the  red  image,  corresponding  to  the  amaurotic  eye,  is 
distinctly  seen  by  hysterics.  Or,  in  a  case  of  unilateral  green-blind- 
ness, a  prism  doubles  the  image  of  a  green  object  and  both  are  perceived 
as  green.  Again,  an  eye  that  fails  to  detect  everything  but  red,  upon 
looking  at  a  revolving  Newton  wheel  bearing  red  and  green,  sees  it  to  be 
whitish,  as  does  the  normal  eye,  proper  cognizance  having  evidently  been 
taken  of  the  complementary  green.  It  is  evident,  therefore,  that  the 
trouble  is  not  in  the  eye  or  in  the  paths  of  conduction,  but  that,  under 
ordinary  circumstances,  the  impression  fails  to  enter  the  field  of  per- 
sonal consciousness.  These  symptoms  are  unattended  by  any  change  in 
the  retina  or  media.  Spiller  ^  insists  that  the  lachrymal  refiex  remains 
in  hysteria  even  when  the  eye-parts  and  the  side  of  the  face  are  anes- 
thetic, while  in  organic  lesions  the  tears  are  not  similarly  secreted  upon 
irritating  the  conjunctiva,  as  with  a  piece  of  paper  placed  under  the 
lid. 

Distribution  of  Hysterical  Anesthesias. — In  a  very  small  pro- 
portion of  cases  the  anesthesia  in  hysteria  involves  the  entire  cutaneous 
and  mucous  extent.  Usually  it  is  limited  (1)  to  one-half  of  the  body  ; 
(2)  to  areas  of  more  or  less  definite  geometric  outline ;  and  (3)  to  dis- 
crete islets. 

Hysterical  hemianesthesia  is  a  common  distribution  of  sensory  de- 
ficiency. Ordinarily,  it  affects  the  left  half  of  the  body,  and  is  sharply 
limited  by  the  median  line.  If  intense,  the  approachable  mucous  sur- 
faces on  the  same  side  are  commonly  also  anesthetic.  As  a  rule,  the 
special  senses — sight,  hearing,  smell,  and  taste — are  blunted  on  the 
anesthetic  side,  but  in  some  cases  the  special  senses  are  affected  on  the 
opposite  side. 

Anesthesia  in  geometrical  areas  is  frequently  encountered.  An  entire 
extremity  or  a  band  about  an  extremity  may  alone  be  anesthetic.  The 
distribution  may  often  be  described  as  a  sleeve,  glove,  sock,  stocking,  or 
drawers-leg  anesthesia.  The  outlines  have  no  relation  to  the  anatomical 
distribution  of  the  nerve-trunks  whatever,  but  are  referable  to  functional 
groupings.  They  often  have  a  superimposed  relation  to  functional  dis- 
turbance, as  in  cases  of  paralyzed  or  contracted  limbs,  diseased  joints,  or 
local  injury.  In  hysterical  amblyopia  the  conjunctiva,  lids,  and  a  cir- 
cular area  about  the  eye  are  usually  anesthetic.  In  hysterical  deafness 
the  auditory  canal  and  concha  are  frequently  insensitive.  In  hysterical 
aphonia  the  larynx  may  be  anesthetic. 

Islets  of  anesthesia  of  peculiar  and  paradoxical  outline  are  sometimes 
encountered.  These  may  be  many  or  few,  and  it  often  requires  minute 
and  painstaking  search  to  find  them. 

1  "  Phila.  Med.  Jour.,"  May  17,  1902. 


580 


NEUEOSES. 


Peculiarities  of  Hysterical  Anesthesia. — 1.  In  the  first  place, 
the  outUnes  of  limited  hysterical  anesthesias,  excepting  hemianesthesia, 
do  not  conform  to  the  anatomical  distribution  of  cutaneous  nerves  or  to  the 
sensory  areas  related  to  the  vertebral  segments,  but  rather  to  the  mental 
association  of  functions,  and  probably  to  their  cortical  representations. 

2.  The  organic  and  tendon  reflexes  in  hysterical  anesthesia  are  not 
modified,  as  in  organic  lesions  marked  by  insensitiveness.      The  2^upU 


Fig.  249.— 1,  Most  common  disposition  of  hysterical  anestliesia.  Black  spots  represent  hysterogenic 
zones  (Dutil).  2,  Hysterical  anesthesia  in  geometrical  segments  (Tourette).  3,  Hysterical  anesthesia  iu 
disseminated  islets  (Pitres). 


responds  to  light  and  accommodation  and  to  pinching  of  the  neck, 
even  when  the  eye  is  amblyopic  and  the  skin  of  the  neck  is  insensitive. 
The  abdominal,  cremasteric,  knee,  and  toe  reflexes  are  not  abnormal.  The 
cardiac  and  respiratory  reflexes  to  painful  cutaneous  stimulation  are  re- 
tained, even  when  an  anesthetic  zone  is  used.  Sometimes  a  spurious 
ankle-clonus  can  be  obtained.  Other  reflexes  dependent  principally 
upon  sensation  are  abolished  by  hysterical  anesthesia.  The  palpebral 
and  pharyngeal  reflexes  disappear   if  the  parts  are  insensitive.      The 


HYSTERIA.  581 

pharyngeal  reflex  is  lost  in  ninety  per  cent,  of  hysterics.  TickVnirj  of  the 
trunk  or  the  j^lantar  surface  does  not  produce  the  usual  responses.  Buz- 
zard lays  especial  emphasis  on  the  loss  of  the  plantar  reflex,  with  reten- 
tion of  the  knee-jerk,  in  hysteria. 

In  many  instances  the  knee-jerk  is  relatively  increased,  and  often  a 
slight  clonus  may  be  obtained  at  the  ankle.  There  is  also  a  tendency 
for  a  tap  on  the  knee  to  induce  jerking  of  the  trunk  or  both  limbs,  in 
addition  to  the  true  knee  phenomenon. 

3.  The  anesthetic  zones  are  movable.  Though  they  may  persist  for 
months,  and  even  years,  they  are  not  absolutely  fixed,  and  often  are  even 
capricious.  A  number  of  things  may  serve  to  promptly  or  gradually 
modify  them.  Hysterical  attacks  frequently  change  the  distribution  of 
the  anesthetic  zones,  and  sometimes  are  preceded  by  an  increase  in  their 
size.  During  such  attacks  the  anesthesia  may  completely  disappear. 
Anesthetics  or  a  dose  of  morphin  or  alcohol  sometimes  cause  its  tempo- 
rary disappearance.  Hypnotic  somnambulism  and  suggestion  may  dis- 
place anesthetic  areas,  and  they  may  disappear  during  sleep.  If  the 
patient's  attention  be  strongly  fixed  on  an  anesthetic  area,  it  may  mo- 
mentarily restore  sensation.  In  the  same  way,  as  pointed  out  by  Patrick, 
the  boundaries  of  the  anesthetic  area  may  enlarge  during  the  course  of 
an  examination,  the  attention  in  this  case  naturally  being  directed  to  the 
loss  of  sensation.  The  action  of  so-called  esthesiogenie  agents  is  supposed 
to  be  largely  due  to  the  attention  and  suggestion  they  invoke.  By  the 
application  to  the  anesthetic  areas  of  a  great  diversity  of  objects,  such  as 
metal  plates,  magnets,  woods,  metals,  minerals,  and  gases,  or  by  the  use 
of  electrical  currents,  especially  faradismand  static  sparks,  the  anesthesia 
may  be  made  to  shift,  sometimes  to  disappear,  and  often  to  transfer  to 
the  opposite  side.  Some  patients  are  susceptible  to  one  agent,  some  to 
another,  apparently  in  proportion  as  their  attention  or  fancy  is  captivated. 
When  the  anesthesia  is  transferred,  it  tends  to  return  to  the  side  whence 
it  was  displaced,  but  in  doing  so  oscillates  from  side  to  side  several  times 
before  finally  locating  in  its  old  habitat.  A  transformation  of  tactile 
into  visual  sensation  sometimes  occurs.  Binet  first  described  this  curious 
phenomenon.  If  letters,  figures,  or  geometrical  outlines  be  traced  with 
the  finger-nail  or  a  pencil  upon  anesthetic  skin  areas,  the  patient  can  see 
them  on  a  blank  wall  or  screen.  Fry  i  also  found  that  if  a  colored 
screen  were  used,  the  patient  described  the  tracing  as  surrounded  by  the 
color  complementary  to  the  one  before  her ;  for  instance,  with  a  blue 
screen  the  figures  appeared  to  be  in  a  red  field. 

4.  It  is  a  striking  and  paradoxical  fact  that  hysterics  are  not 
disturbed  by  their  sensory  losses,  and  are  usually  entirely  ignotrmt  of 
them  until  deciphered  by  a  medical  examination.  For  instance,  the 
small  and  delicate  movements  of  the  fingers  ordinarily  so  dependent 
upon  sensation  may  be  perfectly  performed  by  the  anesthetic  hand  of 
the  hysteric  under  the  guidance  of  the  eye.  Apparently  the  motor 
image  is  called  up  and  exteriorized  through  the  motor  paths. 

5.  It  has  been  noticed  that  a  hand  completely  anesthetic  to  all 
forms  of  sensation  would  yet  grasp  a  pencil  or  other  familiar  object,  and 

^  "Jour.  Ment.  and  Kervous  Dis.,"  Aug.,  1899. 


582  NEUROSES. 

promptly  indicate  its  use,  when  the  patient's  eyes  were  bandaged  and  all 
sensation  denied.  In  the  same  way  an  anesthetic  leg  and  foot  may 
cause  no  inco5rdination  in  walking.  These  paradoxical  features  have 
usually  been  attril^uted  to  deceit  and  simulation,  but  are  presented  by 
similar  cases  the  world  over  without  possibility  of  collusion. 

6.  The  sensory  disturbance  is  frequently  located  by  topical  or 
traumatic  causes.  The  frequency  of  left-sided  hemianesthesia  is 
related  apparently  to  the  lesser  strength  of  the  left  side.  The  super- 
position of  sensory  disturbance  to  inflamed  joints  or  to  injuries  or  to 
points  of  focused  attention  may  often  be  noted. 

Hysterical  hyperesthesias  are  very  common.  Neuralgic  pains 
and  other  disturbance  of  sensation  may  occur  in  hysterics  as  well  as  in 
others,  without  having  any  special  significance,  but  often  from  such  a 
source  or  from  a  blow  or  from  the  mere  fixation  of  attention,  perhaps 
through  misdirected  solicitude  of  the  physician,  there  develops  o. peculiar 
sensitiveness.  This  is  usually  circumscribed.  It  may  involve  a  joint 
(Brodie's  joints)  or  an  entire  limb,  but  is  practically  never  generalized 
or  even  of  hemiplegic  distribution.  It  is  often  confined  to  narrow, 
superficial  zones  or  points,  as  at  the  vertex,  giving  rise  to  the  classical 
clavus,  about  the  breasts,  along  the  spine,  in  the  groins,  and  at  the  pit 
of  the  stomach.  The  glandular  portions  of  the  breasts,  testicles,  and 
ovaries  may  be  similarly  sensitive.  Such  sensitive  spots  are  frequently 
found  in  the  midst  of  anesthetic  areas,  and  while  the  surface  may  be 
exquisitely  sensitive  to  the  touch  of  a  finger,  the  pricking  of  a  pin  may 
cause  no  discomfort.  It  will  frequently  be  found  that  if  the  patient's 
attention  is  strongly  diverted,  the  area  so  intensely  sensitive  may  be  less 
sensitive  than  normal  and  entirely  tolerant  of  firm  and  deep  pressure. 
In  the  same  way,  by  suggestion  or  the  application  of  various  inert  sub- 
stances, the  sensitiveness  may  be,  at  least  momentarily,  suppressed. 
There  is  always  found,  upon  close  investigation  of  such  sensitive  areas, 
paradoxical  peculiarities  similar  to  those  in  the  anesthesias,  and  which 
serve  to  proclaim  their  hysterical  nature. 

If  such  a  hyperesthetic  zone  arises  from  or  becomes  associated  with 
some  mental  storm,  pressure  upon  it  may  serve  to  revive  the  memories 
in  question  and  provoke  a  hysterical  fit.  It  is  then  denominated  a 
spasmogenic  or  hysterogenic  point  or  zone.  The  mental  character  of  hys- 
terical hyperesthesias  is  evident  in  their  genesis  and  associations.  Of  a 
similar  nature  are  the  disagreeable  or  painful  sensations  provoked  in 
rare  cases  by  certain  substances  or  by  heat  or  cold.  Paresthetic  ting- 
lings,  numbness,  etc.,  are  comparatively  rare. 

Motor  Stigmata. — The  motor  stigmata  of  hysteria  must  be  sharply 
distinguished  from  the  motor  accidents  to  be  considered  later.  The 
stigmata  are  usually  unknown  to  the  patient,  and  luust  be  sought  by  the 
physician.  Practically,  they  differ  from  the  accidents  only  in  degree, 
and  show  the  substratum  of  more  marked  errors  of  motor  control,  which 
are  likely  to  develop  as  accidents  at  any  moment.  In  many  ways  they 
are  indicative  of  the  automatism  which  is  one  of  the  most  marked 
features  of  the  psychoneurosis. 

1.  Movements  in  hysteria  are  retarded.     The  reaction  time  is  in- 


HYSTERIA.  '  583 

creased  often  for  the  simplest  movement,  and  in  proportion  to  the  insen- 
sibility of  the  parts  brought  into  play.  The  retardation,  therefore,  is 
closely  allied  to  the  anesthesias.  It  may  be  increased  by  diverting  the 
patient's  attention  or  diminished  by  concentrating  his  attention  upon 
the  given  act.  In  automatic  movements  provoked  subconsciously  or 
under  hypnotism  the  retardation  disappears,  showing  its  psychical  nature. 

2.  Movements  are  maladroit  and  incodrdinate,  unless  carefully  super- 
vised by  the  patient;  and  this,  again,  is  proportionate  to  the  anesthesia 
and  the  obliteration  of  the  muscular  sense.  In  automatic  and  subcon- 
scious movements  the  incoordination  disappears.  Partial  or  complete 
catalepsy  and  automatism  in  such  limbs  may  be  present  if  the  patient 
can  not  see  the  limb  or  otherwise  gain  an  idea  of  its  position. 

3.  Hysterical  patients  are  often  incapable  of  performing  several 
acts  simultaneously,  as  they  are  unequal  to  the  division  of  attention 
thereby  necessitated. 

4.  Voluntary  intentional  movements  are  usually  iveakened.  Patients 
who  may  in  an  automatic  manner  show  great  strength  in  the  per- 
formance of  customary  and  habitual  tasks,  when  asked  to  make  a 
test  effort,  as  upon  the  dynamometer,  register  an  insignificant  amount. 
They  appear  incapable  of  willing  an  effort  of  which  they  do  not  possess 
the  deeply  graven  motor  image.  The  difficulty  again  is  mental — the 
outcome  of  their  diminished  volition  and  attention.  Amyasthenia  is 
most  marked  in  the  insensitive  parts,  and  foreshadows  the  paralytic 
accidents. 

5.  In  many  hysterics  there  is  a  tendency  to  rigidities  or  con- 
tractures. It  may  be  demonstrated  in  weakened  or  anesthetic  limbs, 
and  is  often  indicated  by  exalted  reflexes.  It  may  be  provoked  by  an 
elastic  bandage,  deep  massage  of  the  muscles,  sharp  flexion  or  extension 
of  joints,  faradization,  frictions,  percussion,  and  suggestion,  varying  in 
different  patients.  The  contractures  thus  induced  invade  both  flexors 
and  extensors,  and  fix  the  joint  in  a  characteristic  attitude,  the  same  as 
that  in  the  accidental  and  spontaneous  hysterical  contractures.  By 
similar  means  it  can  be  caused  to  subside.  Charcot  denominated  this 
state  the  diathesis  of  contracture. 

Mental  Stigmata. — The  mental  stigmata  of  hysteria  consist  in  a 
belittlement  of  memory  and  of  will-power.  The  amnesia  is  sometimes 
due  to  the  lack  of  mental  concentration, — the  outcome  of  the  volitional 
enfeeblement, — and  the  loss  of  will-power  is  frequently  manifested  in 
the  impulsive  acts  and  general  want  of  self-control. 

1.  Amnesia. — The  forgetfulness  of  hysterics  accounts  frequently  for 
their  uncertain  and  contradictory  statements,  and  has  often  unjustly  laid 
them  open  to  charges  of  deceit.  In  some  instances  the  memory  loss  is 
systernatized, — that  is,  it  embraces  a  certain  group  of  related  facts  pertain- 
ing to  some  person  or  event,  while  other  contemporaneous  incidents  are 
recalled.  In  the  same  way  a  group  of  motor  images  may  disappear, — 
such,  for  instance,  as  those  for  walking  or  writing  or  for  articulate  speech, 
— and  astasia,  agraphia,  and  motor  aphasia  result.  In  this  way  the  recol- 
lection of  a  certain  person  may  completely  drop  out  of  their  minds,  or 
they  may  lose  all  the  words  of  an  acquired  language.     In  other  cases 


584  NEUROSES. 

the  memorv  loss  may  be  localized;  that  is  to  say,  it  embraces  a  given 
period  of  time.  Frequently  after  a  convulsive  attack,  sometimes  in 
traumatic  cases  after  the  initial  accident,  there  is  a  loss  of  memory  for  a 
variable  period  of  time  antecedent  to  the  incident  in  question,  or  for  a 
period  both  before  and  after  the  mental  disturbance.  Rare  instances  are 
recorded  in  which  the  amnesia  has  been  total  and  complete  for  all  acqui- 
sitions up  to  or  during  a  certain  period  of  life.  Such  patients  begin 
again  to  speak  and  learn  as  children.  In  some  cases  acts  and  impressions 
are  forgotten  immediately.  A  book  or  a  short  story  may  be  read  re- 
peatedly with  full  interest  and  appreciation,  but  is  at  once  forgotten. 
In  all  marked  cases  of  hysteria  there  is  some  blurring  of  recent  memories. 

The  amnesias  of  hysteria  are  analogous  to  the  anesthesias,  and,  like 
them,  under  the  action  of  hypnotism  or  in  subconscious  states,  may  be 
demonstrated  to  be  purely  functional.  The  memory  impressions  do 
exist,  and  they  can  be  revived.  Recovered  cases  similarly  regain  the 
facult}'  temporarily  lost.  Out  of  localized  amnesias  a  double  personality 
may  arise,  as  under  similar  circumstances  the  hysteric  loses  one  grouj)  of 
memories  and  regains  the  other,  alternating  between  the  two. 

Aboidia  implies  absence  of  will-power.  It  expresses  the  impaired 
volition  of  hysterics,  which  reduces  their  powers  of  mental  concentration 
and  attention,  and  renders  them  vacillating,  impulsive,  and  lacking  in 
determination.  In  some  cases  it  attains  such  prominence  that  they  can 
not  bring  themselves  to  undertake  the  simplest  task,  such  as  dressing  or 
undressing,  and  hesitate  at  the  slightest  obstacle. 

Impressionahility  or  suggestibility  is  often  extremely  developed  in 
hysterics,  and  practically  constitutes  a  mental  stigma.  They  are  emo- 
tional and  easily  swayed,  subject  to  the  slightest  influence  and  sensitive 
to  insignificant  impressions.  The  lack  of  will-jDower  renders  them  of 
infirm  and  vacillating  judgment,  so  that  they  often  become  dependent 
upon  others  to  decide  their  slightest  actions.  The  insistent,  underlying, 
fixed  idea  thus  controls  them  the  more  thoroughly. 

Simidation. — From  inadequate  knowledge  of  the  disease,  hysterics 
have  been  supposed  to  simulate  for  the  pleasure  of  it,  and  to  deceive 
for  the  satisfaction  derived  from  notoriety.  To  a  veiy  slight  degree  this 
may  be  true,  but  the  simulation  and  the  deceit  have  their  origin  in 
misconceptions,  in  misconstrued  impression,  or  arise  from  the  failure  of 
impressions  to  reach  the  field  of  consciousness.  Hysterical  young 
women  are  too  commonly  supposed  to  be  erotic.  This  is  sure  to  be  the 
case  if  in  their  attacks  they  show  emotional  attitudes  or  actions  that 
may  be  so  interpreted.  As  a  matter  of  fact,  they  are  usually  frigid. 
Introspection  and  self-concentration  are  fatal  to  the  grand  passion. 
Local  anesthesias  or  hyperesthesias  may  completely  destroy  the  generic 
sense. 


ACCIDENTS  OF  HYSTERIA. 

We  come  now  to  the  more  or  less  transitory  features  of  hysteria,  the 
accidents,  chief  among  which  are  the  hysterical  attacks.  These  often 
take   the   form  of  severe,  intense,  and  prolonged  convulsions.     AVhile 


HYSTERIA.  585 

uncommon  in  this  country,  they  are  occasionally  observed  in  the  most 
typical  form.  Ordinarily,  however,  the  attack  is  partial  or  larvated. 
Only  by  an  understanding  of  the  extreme  variety  will  we  be  able  to  esti- 
mate the  simpler  forms,  which  usually  consist  of  isolated  elements  of 
the  ty]>ical  f/rancle  attaque  of  Charcot. 

Hysterical  Convulsive  Attacks. — The  complete  grand  attacks, 
as  studied  and  described  by  Charcot  and  figured  by  Richer,  are  infre- 
quent, but  in  some  irregvlar  or  fractional  form  they  occur  in  the  very 
large  majority  of  all  cases  of  hysteria.  Patients  possessing  spasmogenic 
zones  may  usually  be  thrown  into  a  convulsion  by  firm  pressure  on  these 
points,  and  during  the  seizure  similar  pressure  again  commonly  causes  it 
to  subside.  Emotional  disturbances  may  cause  the  attacks  or  they  may 
apparently  come  on  spontaneously. 

The  grand  attack  consists  of  a  premonitory  stage,  followed  by  four 
periods:  (1)  The  prodromal  stage  varies  in  different  patients,  but  is 
uniform  for  the  given  case.  Some  patients  are  depressed,  taciturn,  and 
moody;  others  exhilarated,  restless,  quarrelsome,  and  talkative.  Many 
have  hallucinations  of  sight  or  of  hearing,  referred  in  the  direction  of  the 
anesthetic  side,  and  the  insensitive  areas  may  be  increased.  Usually, 
palpitations  and  vasomotor  storms  are  observed.  There  may  be  nausea, 
hiccup,  trembling,  and  the  discharge  of  a  large  quantity  of  urine. 
The  aura  follows.  This,  ordinarily,  consists  of  a  painful  feeling  arising 
in  the  lower  part  of  the  abdomen,  and  develops  into  the  sensation  of  a 
rounded  body,  which  mounts  upward,  and,  as  it  reaches  the  neck,  gives 
rise  to  feelings  of  strangulation  or  suffocation — the  globus  hystericus. 
The  face  may  flush,  hissing  is  heard  in  the  ears,  throbbing  is  felt  in  the 
temples,  objects  turn  dark  before  the  eyes,  vertigo  occurs,  and  the 
patient  sinks  down,  or  even  falls  suddenly,  unconscious,  and  the  fit 
begins.  In  many  instances  the  fit  does  not  develop,  and  in  a  moment 
the  patient  is  relieved,  or  the  globus  may  last  for  hours  without  eventu- 
ating in  a  fit.  Sometimes  this  train  of  symptoms  is  incited  by  emotional 
disturbance  arising  from  insignificant  irritation,  or  any  strong  mental 
impression  may  induce  it. 

2.  The  epileptoid  period  closely  mimics  the  features  of  an  epileptic 
attack.  There  may  even  be  an  initial  harsh  noise  or  slight  cry.  The 
patient  is  rigid  ;  the  face  is  pale,  but  promptly  becomes  red,  and  the  neck 
is  congested  and  swollen.  Frequently  the  tongue  is  protruded  or  the 
teeth  may  be  ground  together.  Biting  the  tongue  and  involuntary  uri- 
nation are  uncommon,  but  do  occur.  Usually  the  convulsion  is  most 
marked  on  the  anesthetic  side  to  which  the  face  is  turned.  The  tonic  phase 
lasts  two  minutes  or  less,  and  is  often  attended  by  slow^,  rigid  move- 
ments of  wide  range,  with  notable  extension  of  the  feet  and  supination 
of  the  hands  or  movements  of  circumduction,  unlike  anything  seen  in 
epilepsy.  The  fingers  are  usually  clenched  over  the  thumb,  which  may 
protrude  between  them  ;  the  chest  and  abdomen  are  fixed  and  the  body 
is  rigid.  This  tonic  phase  is  followed  by  a  clonic  phase,  in  which  rapid, 
small  oscillations  begin  in  the  rigid  members  and  in  the  face.  The  sus- 
pended respiration  reappears  in  broken,  arrhythmical  gasps  and  sobs,  the 
chest  and  abdomen  acting  independently.     Noisy  movements  of  swallow- 


586 


NEUEOSES. 


Fig.  250. — Tonic  phase,  the  tongue  rolling  from  one  angle  of  the  mouth  to  the  other  (Richer). 


Fig.  251.— Schematic  representation  of  the  wide  tonic  movements  (Richer). 


Fig.  252. — Tonic  phase,  circumduction  movements  of  upper  members  (Richer). 


Fig.  253. — Clonic  phase,  schematic  representation  of  clonic  movements  (Richer). 


Fig.  2.54.— Phase  of  resolution  (Richer). 


HYSTERIA. 


587 


ing:  and  sonorous  l)oii)oryg;mi  tire  frequently  produced.  All  the  clonic 
movements  are  indei)endent  and  illogical.  This  piuise  may  last  several 
minutes  and  gradually  subside,  the  patient  falling  into  a  jjluine  of  resola- 


Fig.  255. — Phase  of  resolution,  retaining  partial  contractures  (Richer). 


Fig.  2.56. — Posterior  arc  de  eercle  (Eicher). 


Fig.  257.— Anterior  arc  de  eercle  (Knobloch). 


Fig.  258. — Lateral  arc  de  eercle  (Richer). 


Hon,  in  which  .some  rigidity  may,  however,  persist.      Stertor  and  froth- 
ing saliva  may  appear,  and  sometimes  general  twitchings  or  sharp  spasms 


588 


NEUROSES. 


may  still  agitate  the  patient  at  intervals.     The  pupil  may  not  respond 
to  light. 

3.  Tlie  Period  of  Cloicnism. — After  the  phase  of  resolution  of  the 
epileptoid  period  has  lasted  a  short  time,  the  second  period  develops.  It 
is  made  up  of  two  phases, — (a)  a  phase  of  contortions,  or  illogical  atti- 
tudes, and  [b)  a  phase  of  wide-ranged,  or  grand,  movements.  The  con- 
tortions of  the  first  phase  are  usually  steadily  maintained  for  several 
minutes,  thereby  varying  essentially  from  the  grand  movements  of  the 


Fig.  259. — Passional  attitude  of  strug 
assailant  (Richer). 


ing  with  an 


Fig.  260. — Passional  attitude  of  solici- 
tation (Richer). 


Fig.  261.— Zoopsia  (Richer). 


Fig.  262.— Delirium  of  the  fourth  period  (Richer). 


second  phase,  which  are  repeated  with  more  or  less  rapidity.  One  'of 
the  most  common  and  characteristic  contortions  is  an  exaggerated  opis- 
thotonos, or  arc  de  cercle.  This  may  also  be  executed  forward  or  later- 
all  v.  To  these  contortions  succeed  alternate  flexions  and  extensions  of 
the  trunk  or  of  the  limbs,  or  rotations  of  the  head.  This  phase  is 
attended  usually  by  violent  outcries,  and,  in  evident  fear  or  rage,  the 
patients  tear  their  garments,  grimace  in  a  horrible  manner,  and  put 
forth  an  astounding  amount  of  strength  against  those  trying  to  control 


HYSTERIA.  589 

them.  In  tliis  pliase  they  often  bite,  scratch,  and  strike  at  their  at- 
tendants, apparently  under  tlie  domination  of  the  halhicinations  of  a 
fixed  dream  or  dekisional  storm. 

4,  Period  of  Passional  Attitudes. — The  third  period  is  the  gradual 
outgrowth  and  logical  continuation  of  the  second.  The  patient  drama- 
tizes in  pantomime  the  acts  of  the  dream  that  embraces  circumstances  of 
the  past  life,  or  perhaps  the  incidents  connected  with  the  origin  of  the 
hysterical  condition.  Terror,  love,  gaiety,  rage,  eroticism,  singly  or  by 
turn,  animate  the  features  and  compel  the  attending  attitudes  and 
gestures.  The  acts,  emotions,  and  attitudes  of  one  attack  are  usually  re- 
peated with  fidelity  at  each  succeeding  crisis  by  a  given  case.  If 
one  knows  the  nature  of  the  dream,  it  is  easy  to  anticipate  its  manifes- 
tation. 

5.  The  period  of  delirium  is  a  prolongation  of  the  dream  state  of 
the  third  period.  It  still  pursues  and  dominates  the  patient,  who  now 
talks  in  the  delirium  and  verbally  expresses  his  hallucinations,  which 
usually  have  to  do  with  disagreeable  sights,  animals,  and  acts.  The 
panorama,  in  which  red  often  predominates,  unrolls  from  the  anesthetic 
side.  The  passional  attitudes  may  be  occasionally  repeated.  The 
delirium  may  be  gay,  furious,  sad,  or  obscene,  and  the  language  and 
actions  correspond.  After  a  varying  time  the  hallucinations  fade,  sad 
memories  may  recur,  with  sobs  and  tears,  and  suddenly,  or  after  a  few 
moments'  silence,  the  patient  arouses,  a  little  fatigued,  and  at  once  fully 
recovers  his  former  conscious  state. 

The  duration  of  a  grand  attack  is  variable,  but  on  an  average  recpiires 
from  fifteen  minutes  to  half  an  hour.  The  prodromal  stage  and  the 
fourth  period  may  be  very  long.  The  epileptoid  period  rarely  exceeds 
three  minutes ;  the  second  period  ordinarily  lasts  five  to  ten  minutes ; 
the  third  is  still  longer.  In  some  instances  one  attack  follows  another 
without  appreciable  interval,  or  some  feature  of  the  attack,  as  the  stupor 
of  the  first  period  or  the  delirium  of  the  fourth,  may  be  prolonged  for 
hours  and  days,  constituting  a  status  hystericus.  The  following  table 
may  serve  to  systematize  the  features  of  the  grand  attacks  : 

r  Mental  disorders  and  hallucinations. 
Premonitory  stage.  {  Prodromes.        ]  Functional  organic  disorders. 

°  *-  I   Motor  and  sensory  disorders. 

L  Aura,  globus, 
r  Onset. 
Enilentoid  t  e  i  d  I  Tonic  phase.     Slow  movements  and  tetanic  rigidity. 

^     ^         ^  ■  j   Clonic  phase.     Small,  quick  movements. 

[  Phase  of  resolution.  •{    Sopor,  stertor. 

-n    •   1    i?    1        •  f  Phase  of  contortions,  arc  de  cercle. 

Period  01  clown  ism.  i  du         i-  i  *        i     ™ 

(  Phase  or  large  movements,  salaams. 

Passional  period.  -{  Passional  attitudes  and  actions. 

Period  of  delirium.  -J  Delirium,  hallucinations,  zoopsia. 

Modified  or  Partial  Attacks. — The  typical  grand  attack  may  be 
infinitely  modified.  It  may  be  intensified  or  reduced  in  severity,  but, 
what  is  of  more  importance,  it  may  be  disaggregated,  and  almost  any 
feature  of  it  may  occur  alone  as  a  partial  attack.     These  partial  attacks 


590  NEUEOSES. 

may  also  be  indefinitely  prolonged  in  a  condition  of  status.      Some  of 
the  most  commonly  encountered  ones  follow  : 

Vertiginous  Attacks. — The  premonitory  vertigo,  obscuration  of  vision, 
ringing  in  the  ears,  and  sinking  feeling  may  recur  repeatedly,  without 
other  features  of  the  attack. 

Globus  attacks  are  among  the  most  common  of  the  larvated  seizures. 
The  patient  suddenly  feels  the  discomfort  at  the  throat,  or  it  may  slowly 
appear,  and  only  disappear  after  a  considerable  period. 

Epileptoid  Attacks. — The  attack  may  cease  with  the  phase  of  resolu- 
tion belonging  to  the  first  period,  or,  recurring  at  this  point,  strongly 
simulate  the  epileptic  status.  The  differential  diagnosis  is  often  ex- 
tremely difficult,  the  more  so  as  epilepsy  may  affect  a  hysterical  subject, 
and  convulsive  manifestations  of  both  neuroses  may  alternate. 

Tetanic  Attacks. — The  seizure  may  be  limited  to  the  first  phase  of 
the  second  period.  The  arc  de  cercle  suddenly  appears,  and  may  per- 
sistently endure,  or  to  it  may  be  added  the  clownism,  with  wide  move- 
ments, giving,  for  instance,  salaam  attacks.  Rage,  joy,  and  other  emo- 
tions may  then  modify  the  movements  and  the  attitudes,  and  demoniacal 
or  maniacal  attacks  are  presented,  in  which  the  patient  may  be  extremely 
wild  and  unmanageable. 

Attacks  of  ecstacy  are  manifestations  of  the  passional  attributes  of 
the  third  period.  With  or  without  premonition  or  aura,  the  patient 
suddenly  becomes  motionless,  and  the  face  expresses  astonishment,  admi- 
ration, adoration,  or  stupor.     Cataleptic  features  are  often  added. 

^yncopcd  Attacks. — After  an  aura  or  some  feeling  of  discomfort  the 
patient  relaxes  and  becomes  inert  and  apparently  unconscious.  The 
hands  may  be  clenched  or  a  tremor  of  the  eyelids  may  indicate  the 
spasmodic  state.  Respiration  slows,  the  face  may  be  pale  or  slightly 
flushed,  but  the  pulse  is  unaffected.  This  attack  may  be  prolonged  into 
the  sleep  attack. 

Attacks  of  Sleep. — This  lethargic  or  trance-like  condition  may  follow 
several  ordinary  attacks,  or  some  emotional  storm  may  induce  it.  Its 
onset  may  be  gradual,  or  sudden  and  apoplectic.  The  appearance  is 
one  of  natural  sleep,  but  careful  search  will  often  detect  slight  contrac- 
tures, as  in  the  eyelids,  which  do  not  easily  yield  to  the  finger,  in  the 
ocular  squint,  or  the  position  of  the  hands  and  feet.  Frequently  there 
is  a  marked  tendency  to  catalepsy,  and  the  limbs  retain  any  position  pas- 
sively given  them.  The  pupils  are  sensitive  to  light,  and,  though  gen- 
eral sensation  seems  abolished,  it  is  only  masked,  as  such  patients  fre- 
quently report  all  that  has  occurred  during  the  sleep.  The  pulse-rate, 
ordinarily  normal,  may  be  diminished  or  increased.  The  respiration  is 
usually  shallow  and  reduced  in  frequency.  The  temperature  maybe 
normal,  sul^normal,  or  slightly  elevated.  Such  attacks  may  last  minutes, 
hours,  or  months,  and  terminate  commonly  by  a  convulsive  attack,  by 
laughter  or  tears,  or  a  few  delirious  words. 

Somnambidic  Attacks. — Some  patients,  under  a  sudden  impulsion, 
start  on  long  flights  or  make  considerable  journeys,  in  which  they  may 
travel  great  distances  and  consume  many  days.  Finally,  they  come  to 
themselves  in  great  surprise  at  being  from  home,  and  may  have  no  rec- 


HYSTERIA.  591 

ollection  of  the  intervening  events.  In  a  succeeding  attack  they  may- 
recall  everything  that  transpired  in  the  first,  and,  by  a  repetition  of  such 
protracted  attacks,  build  up  a  double  existence  or  personality,  or  the 
morbid  state  may  eventually  completely  displace  the  normal  one.  In 
lessened  degree  automatism  and  somnambulic  attacks  of  short  duration 
are  not  uncommon  in  hysteria. 

Motor  Accidents. — Paralyses  and  Contractures. — Both  the 
paralyses  and  contractures  of  hysteria  are  foreshadowed  by  the  stig- 
mata of  amyasthenia  and  the  diathesis  of  contracture,  of  which  they 
may  be  considered  temporary  exacerbations.  They  are  frequently 
combined  in  a  given  patient,  and  even  in  a  given  limb.  They  may 
follow  :  (1)  Convulsive  attacks  ;  (2)  mental  impressions  or  shocks  ;  (3) 
traumatism ;  and  (4)  various  morbid  states.  It  happens  that  after  a 
convulsive  attack  a  hemiplegic,  paraplegic,  or  monoplegic  palsy  super- 
venes and  tends  to  persist  for  a  considerable  time.  The  other  in- 
citing causes  mentioned  act  with  less  rapidity,  and  there  is  usually, 
even  in  traumatic  cases,  an  intervening  period  of  freedom  from  motor 
difficulties, — a  period  of  meditation,  as  Charcot  denominated  it,  or 
of  autosuggestion, — lasting  a  few  hours  or  several  days.  In  addition,  it 
is  to  be  noted  that  there  is  no  necessary  relation  between  the  severity  of 
the  physical  exciting  cause  and  the  extent  or  completeness  of  the  paralysis 
and  contractures.      They  are  relative,  however,  to  the  mental  shock. 

Paralyses  of  hysteria  are  commonly  marked  by  a  sudden  emotional 
onset,  or  they  may  gradually  develop  after  some  such  moral  storm. 
Rarely  do  they  abolish  every  movement  in  a  limb,  and  close  obser- 
vation will  usually  detect  slight  evidences  of  voluntary  or  automatic 
motility.  The  antagonistic  muscle-groups  are  equally  affected  and 
the  limb  is  quite  limp.  There  are  vasomotor  and  trophic  disorders 
in  very  exceptional  instances  only.  The  local  temperature  may  be 
slightly  reduced,  and  edema  be  encountered.  Electrical  and  tendon 
responses  are  normal.  There  may  be  superficial  or  deep  anesthesia  or 
hyperesthesia.  Variations  of  the  extent  and  intensity  of  the  paralysis 
follow  various  influences  or  occur  spontaneously.  Ordinarily,  hysterical 
palsies  terminate  in  complete  recovery,  but  may  last  days  or  years.  In 
some  instances  they  are  succeeded  by  contractures,  or  palsy  and  contrac- 
tures alternate.  In  rare  instances  the  paralysis  is  clearly  ideational,  in 
that  it  occurs  only  for  certain  groups  of  voluntary  movements,  such  as 
those  of  writing  or  walking. 

Hysterical  contractures  present  loss  of  power,  with  persistent  invol- 
untary rigidity,  without  modification  of  the  electrical  or  tendon  re- 
sponses. It  is  a  rigid  palsy.  The  affected  limb  is  more  or  less  rigid, 
the  muscles  are  tense  and  firm,  and  the  contractures  persist  during  sleep, 
but  yield  completely  during  general  anesthesia.  Trophic  disorders  are 
rare,  except  in  cases  of  several  years'  standing,  when  the  muscles  may 
be  changed  by  actual  fibrosis  and  permanent  surgical  deformities  result. 
Ordinarily,  there  is  superficial  or  deep  anesthesia,  or  superficial  sensi- 
tiveness. In  slight  cases  the  contractures  may  subside  during  sleep. 
Rare  cases  present  exquisite  sensitiveness  and  severe  paroxysms  of  pain. 
Commonly  the  onset  and  termination  are  abrupt,  but  may  be  gradual. 


592  NEUROSES. 

Contractures,  once  developed,  show  a  tendency  to  protracted  duration. 
They  impress  characteristic  attitudes  upon  the  limbs.  The  arm  is  usually 
adducted  ;  the  elbow,  wrist,  and  fingers  forcibly  flexed.  The  hand, 
when  alone  affected,  may  be  flexed  into  a  fist,  with  thumb  under  or  be- 
tween the  fingers,  or  the  hand  may  be  extended  or  held  in  the  writing 
position.  The  lower  extremity  is  commonly  extended  in  all  its  joints. 
Karely,  the  foot  is  dorsally  flexed.  The  muscles  of  the  trunk  are 
not  infrequently  contractured,  causing  deviations  of  the  spinal  column 
mimicking  scoliosis  and  anterior  and  posterior  curvatures.  The  toes 
may  be  extended  or  flexed.  Many  of  these  attitudes  are  transiently 
represented  in  the  hysterical  attacks,  as  shown  in  the  figures  on  pages 
586  and  587,  and  in  some  sense  hysterical  contractures  or  palsies  may 
be  considered  prolonged  localized  attacks,  or  as  a  hysterical  status  of 
fractional  extent. 

Some  of  the  more  common  varieties  of  hysterical  motor  accidents 
follow. 

Hysterical  hemiplegia  is  most  frequent  on  the  left  side  and  is  usually 


Fig.  'Ji;:!.— Il\-li"rical  contracture  in  foot  and  leg. 

incomplete,  most  aifecting  the  distal  portions  of  the  limbs.  Instead 
of  walking  with  the  rigidity  of  organic  hemiplegia,  the  foot  and  leg  are 
limply  dragged  along  the  ground,  the  advance  being  made  by  the  sound 
side.  Ordinarily,  there  is  anesthesia  of  similar  hemilateral  extent  or 
other  sensory  stigmata  on  the  same  or  opposite  side.  Commonly  the 
face  escapes,  and,  when  affected,  the  lower  half  is  most  implicated. 
Almost  invariably  limited  contractures  will  at  the  same  time  be  found, 
or  they  may  predominate  over  the  flaccidity  or  alternate  with  it. 

Hysterical  monoplegias  may  be  single  or  midtiple.  Their  distribution 
may  be  unilateral  or  crossed.  The  face  and  limb  on  the  same  or  op- 
posite sides,  or  both  lower  limbs,  or  all  four  limbs  may  be  affected. 
Usually  the  paralytic  member  is  not  affected  in  its  totality,  and  presents 
an  anesthesia  of  greater  extent  than  the  paralysis  and  of  characteristic 
geometric  outline.  The  paraplegic  variety  may  disturb  the  urinary  con- 
trol, mainly  through  the  anesthesia  of  the  mucous  surfaces. 

The /ace  may  be  affected  either  by  paralysis  or  contracture.  In  the 
paralytic  variety  the  upper  portion  of  the  face  usually  escapes,  as  in 
brain-lesions.      In  the  spasmodic  variety  the  lips  and  tongue  are  most 


HYSTERIA.  '  593 

affected,  and  an  appearance  of  palsy  on  the  opposite  side  is  induced  as 
the  contracture  drags  the  mouth  to  its  own  side.  The  spasm  in  the 
face  and  tongue  is  exaggerated  by  liaving  the  mouth  opened  and  the 
tongue  protruded. 

Torticollis  may  ho  due  to  contraction  or  to  paralysis,  and  the  vicious 
position  of  the  head  corresponds.  Contractures  may  be  confined  to  the 
eyelids,  giving  a  false  appearance  of  unilateral  or  bilateral  ptosis.  The 
rigidity  and  resistance  of  the  eyelids  and  the  depressed  eyebrows  dis- 
tinguish it  from  paralysis  of  the  levator,  in  which  the  eyelids  are 
relaxed  and  the  eyebrow  elevated. 

Contractures  and  paralyses  of  the  OGiilar  muscles  are  seldom  seen,  but 
do  occur.  Convergent  strabismus  may  appear.  Conjoined  movements 
mav  be  impossible  upon  voluntary  effort,  but  take  place  inadvertently. 
Divergent  squint,  palsy,  or  contracture  of  a  single  rectus  or  oblique 
are  not  seen  in  hysteria.  Pupillary  stasis  is  not  an  extreme  rarity. 
Karplus  ^  contends  that  in  the  majority  of  cases  during  hysterical 
attacks  the  pupil  does  not  respond  to  light,  and  that  this  may  also  be 
the  case  in  minor  attacks. 

Hysterical  coxalgia  may  present  all  the  attitudes  of  organic  hip- 
disease,  though  abduction,  outward  rotation,  and  apparent  lengthening 
are  rare.  The  apparent  deformity  subsides  under  anesthesia,  and  the 
joint  is  found  free  and  smooth.  The  joint  also  is  not  sensitive  to 
percussion  over  the  trochanter,  or  from  the  knee.  Commonly  there  is 
an  area  of  cutaneous  sensitiveness,  which  is  bounded  by  the  iliac  crest 
and  Poupart's  ligament  above  and  a  horizontal  line  below  the  trochanter. 
This  may  also  be  hysterogenic.  Hysterical  edema  may  mimic  the  local 
swelling  and  redness  of  actual  disease,  and,  indeed,  hysterical  signs  may 
be  added  to  the  true  malady. 

Astasia  abasia  is  a  hysterical  condition  characterized  by  abolition 
or  disturbance  of  the  co5rdinate  movements  for  walking  and  standing 
In  bed  or  on  a  chair  the  patient  may  show  full  coordinate  control  of  the 
legs,  but  may  be  unable  to  stand  unsupported,  or,  if  able  to  stand,  is 
unable  to  walk.  Some  such  cases,  while  unable  to  walk,  can  run,  leap, 
hop,  or  climb  with  ease.  The  difficulty  is  due,  as  already  indicated,  to  a 
systematized  amnesia. 

Hysterical  rhythmical  spasms  affect  the  limbs,  face,  or  neck, 
■causing  movements,  the  same  as  those  purposely  executed  in  health,  but 
steadily  repeated  with  considerable  force.  They  occur  in  attacks  lasting 
from  a  few  minutes  or  a  few  hours  to  several  days.  They  cease  during 
sleep,  and  apparently  consist  of  a  fractional  part  of  a  major  attack. 
Among  such  rhythmical  attacks  may  be  named  the  nodding  spasm,  in 
which  the  head  is  nodded  or  shaken  or  rotated  involuntarily,  and  so 
forcibly  that  it  is  impossible  to  check  it  by  manual  strength.  The 
choreic  dance  or  saltatory  chorea,  which  played  so  important  a  part 
in  medieval  epidemics,  is  of  this  nature.  Some  patients  move  the  arms 
as  if  using  a  hammer  or  other  implement,  and  in  general  the  rhyth- 
mical spasms  show  the  dominance  of  a  fixed  idea.  In  a  similar  way 
the  diaphragm  may  be  affected,  causing  a  peculiar,  hoarse,  barking  cougJi. 

1  "Jahrb.  f.  Psych.,"  1898. 
38 


594  NEUROSES. 

Sneezing  or  grunting  may  be  repeated  in  more  or  less  prolonged  attacks. 
In  very  rare  instances  the  movements  may  closely  simulate  the  incoor- 
dinate, involuntary,  arrhythmical  action  of  Sydenham's  chorea. 

Hysterical  tremors  are  of  great  interest,  and  often  present  very 
difficult  diagnostic  proljlems.  In  hysteria,  and  as  an  accident  of 
hysteria,  we  may  encounter  all  varieties  of  tremor,  not  excepting  the 
intentional  form  that  is  so  striking  a  feature  of  insular  sclerosis. 
Hysterical  tremors  may  be  localized  or  generalized,  fine  or  coarse,  rapid 
or  slow,  intermittent  or  persistent,  and  may  last  for  months  and  years. 
The  tremor  of  Graves'  disease,  of  paralysis  agitans,  of  senility,  and  of 
metallic  poisonings  may  be  exactly  counterfeited  by  hysteria.  In  some 
cases  the  tremor  comes  on  in  spells  or  attacks,  in  some  instances  it  is 
limited  to  the  anesthetic  side  or  to  an  insensitive  member,  and  in  gen- 
eral its  exact  relation  depends  upon  the  escort  of  hysterical  stigmata. 
The  combination  of  hysteria  with  the  organic  diseases  which  are  marked 
by  tremor  is  veiy  common.  This  is  especially  true  of  multiple  sclerosis 
and  the  metallic  poisonings.     Charcot  gave  the  following  classification  : 

Hysterical  Tremors. 

'  1.  Oscillatiug  tremors,   f  Imitate  paralj^sis  agi- 
three    to    six    per  \      tans  or  senile  trem- 

.     /  Tremors,  not  increased  by 
■  1      voluntary  movements. 


B. 


second.  (      hlin^ 

Vibratinsr  tremors,    ^  t    -^  .     n  »    j- 

eight    to    nine    or  |  ^"^'^^^^  ^^^'^^^''^    ^i^' 
more  per  second.       '■      ^^^^* 

Tremors,  occurring  at  rest 
or  not,  provoked  or  ex- 
aggerated   by  voluntary  <  3.  Intention   tremors,   (  Imitate   insular  scle- 
not  J 


movements  which  do  not  J       five   to    seven    j^er  J       rosis  or    mercurial 
accelerate  their  rapidity,   [      second.  (      tremor, 

but  augment  their  am- 
plitude. 


Hysterical  tics  may  be  considered  as  fractional  rhythmic  spasms, 
occurring  with  more  or  less  irregularity.  Like  tics  in  general,  they 
have  a  purposive  character,  and  are  the  expression  of  a  fixed  though 
usually  subconscious  idea.  AVinking,  grimacing,  shrugging,  sniffing, 
coughing,  movements  of  the  hands,  jerking  of  the  legs,  which  may 
cause  jumping,  etc.,  are  encountered. 

Sensory  Accidents. — Painful  Accidents. — Owing  to  their  more 
insistent  nature  the  sensory  accidents  of  hysteria  are  nearly  all  of  a  pain- 
ful character.  Sudden  amblyopia  and  deafness  have  already  been  men- 
tioned among  the  stigmata,  but  may  appear  transiently  as  accidents. 

Hysterical  cephalalgia  may  be  deep-seated  or  superficial,  in  which  case 
it  is  marked  by  a  hyperesthetic  zone.  In  rare  instances  it  is  most  pro- 
nounced in  the  eyeball.  It  is  likely  to  occur  in  periodic  attacks,  es- 
pecially toward  night,  may  be  attended  by  vomiting  and  prostration^ 
and  is  sometimes  intense.  It  may  be  confounded  with  luetic  headache, 
migraine,  the  pain  of  cerebral  tumor,  even  with  that  of  meningitis. 

Hysterical  pseudomeningitis   is    occasionally    encountered   and    may 


HYSTERIA.  595 

deceive  the  elect.  It  may  present  malaise,  loss  of  appetite,  pains  in  the 
head,  increasing  to  an  insupportable  intensity  and  leading  to  delirium. 
Vomiting,  rigidity  of  the  neck  and  extremities,  fever,  vasomotor  streaks, 
and  convergent  squint  may  be  added.  Only  a  history  of  antecedent 
hysteria,  an  active  pupil,  a  regular  pulse,  an  al)sence  of  the  dissociation 
between  temperature,  pulse,  and  respiration,  and  the  presence  of  hys- 
terical stigmata  will  enable  a  diagnosis  if  spinal  puncture  gives  negative 
results. 

SpinnI  irntability  and  tenderness  are  frequent,  and  sometimes  consti- 
tute the  dominant  symptoms.  The  sensitiveness  is  exquisite,  and  may 
be  localized  over  a  few  vertebrae,  simulating  Pott's  disease,  or  extend 
the  length  of  the  spine.  In  many  instances  it  is  especially  severe  over 
the  coccyx.  The  lightest  touch,  even  the  contact  of  the  clothing,  may 
be  painful,  and  the  patient  can  neither  lean  back  in  chairs  nor  lie  on  the 
back.  Usually,  if  the  patient's  attention  can  be  completely  distracted, 
the  sensitive  zone  is  found  tolerant  even  of  vigorous,  deep  pressure.  It 
is  analogous  to  the  hysterical  hyperesthetic  joints  and  localized  hyper- 
esthesias. 

Visceral  neiuxdgias  are  often  marked  by  superimposed  hyperesthetic 
stigmata,  and  may  give  rise  to  the  suspicion  of  gastric  or  intestinal  ulcer 
or  malignant  disease,  or  ape  the  crises  of  tabes. 

Hysterical  angina  pectoris  may  exactly  trace  the  features  of  steno- 
cardiac  attacks.  In  some  cases  it  may  attend  an  actual  organic  lesion, 
but  usually  there  is  no  evidence  of  cardiac  disease,  and  hysterical 
hyperesthesia  in  the  precordial  region  is  present.  Such  attacks  are 
likely  to  occur  in  the  night,  and  may  have  their  starting-point  in  a  dream. 
Often  they  are  preceded  or  followed  by  emotional  disturbance  of  a 
hysterical  sort.  Generally,  the  attacks  are  of  short  duration,  but  may 
persist  for  several  days  in  a  sort  of  status.  The  prognosis  is  not  entirely 
favorable,  in  view  of  the  fact  that  it  is  impossible  to  absolutely  exclude 
an  organic  condition  during  life. 

Visceral  Accidents. — Respiratory  Apparatus. — Associated  with 
laryngeal  paralysis  and  anesthesia,  aphonia  is  encountered.  It  usually 
appears  suddenly.  The  patient  may  whisper  or  execute  low  tones. 
Sonorous  cough  generally,  and  sometimes  singing,  may  remain  unim- 
paired, showing  the  ideational  disturbance  of  vocalization  and  the 
systematized  defect.  Such  patients  may  talk  in  their  sleep  with  a  voice 
of  normal  qualities.  The  laryngoscope  may  show  the  vocal  bands 
unduly  separated  or  approximated.  Mutism  is  more  clearly  a  cerebral 
defect,  a  systematized  motor-speech  amnesia.  It  may  or  may  not  be 
attended  by  aphonia.  In  rare  instances  agraphia  has  been  present,  but 
ordinarily  the  patient  writes,  gestures,  and  otherwise  readily  expresses 
ideas.  The  mouth  parts  usually  are  entirely  mobile  and  free,  but 
sometimes  the  tongue  is  contractured  and  can  not  be'  protruded. 
Hysterical  stammering  has  also  been  recorded.  Mirror  speech  is  some- 
times hysterical.  The  patient  enunciates  words  backward.  Repeated 
more  or  less  rhythmic  cries,  sobs,  barfcs,  hiccups,  sneezing,  laughter^ 
grunts,  and  various  noises  are  met  with,  of  which  the  type  is  the 
hysterical  cough.     They  are  often  attended  by  sensations  of  a  foreign 


596  NEUROSES. 

body  in  the  nasal  chambers  or  pharynx,  and  appear  usually  in  attacks 
occurring  at  various  intervals,  and  presenting  a  variable  duration.  They 
cease  during  sleep.  The  cough  is  very  frequent  in  hysterics  of  pubes- 
cent age,  and  may  appear  as  the  sole  manifestation  of  the  disease.  A 
mental,  moral,  or  physical  shock  may  induce  it,  or  abnormal  conditions 
in  the  nasopharynx  may  be  the  starting-point.  Acute  inflammation  or 
adenoids  should  be  suspected. 

Hysterical  dyspnea  may  be  (1)  of  sudden  onset,  due  to  laryngeal 
spasm  ;  (2)  it  may  result  from  contracture  or  paralysis  of  the  diaphragm, 
and  (3)  it  may  consist  of  an  extremely  rapid  breathing,  reaching  60  or 
100  respirations  a  minute.  The  laryngeal  spasm  is  a  rare  accident,  but  is 
very  alarming  when  it  does  occur,  and  has  resulted  fatally.  Ordinarily, 
relaxation  occurs  when  a  certain  degree  of  apnea  has  been  reached.  In 
the  form  marked  by  rapid  respiration  there  may  be  no  discomfort  or 
effort,  and  the  pulse  is  usually  normal  in  rate  and  character. 

Pulmonary  congestion  and  hemoptysis  are  not  very  rare.  Usually 
there  is  dullness  at  the  apex,  which  may  strongly  suggest  phthisis, 
but  lacks  the  cachexia  and  temperature,  and  the  sputum  is  free 
from  bacilli. 

Dig-estive  Apparatus. — Hysterical  anorexia  sometimes  reduces  the 
patient  to  the  lowest  level  of  inanition.  Patients  reach  such  a  degree 
of  emaciation  that  they  are  practically  living  skeletons,  and  life  is  all 
but  extinct.  A  fatal  termination  is  quite  possible.  The  origin  of  this 
state  is  in  some  fixed  idea  of  suicide  or  of  expiation.  It  may  even 
arise  from  some  trivial  fear,  as  of  growing  too  fat.  In  some  instances 
an  esophageal  spasm  causing  dysphagia  leads  to  the  refusal  of  food,  or 
it  may  follow  vomiting.  Hysterical  vomiting  occurs  in  attacks  which 
may  last  days,  weeks,  and  months.  Food  is  simply  regurgitated  or 
violently  expelled  after  a  short  stay  in  the  stomach.  Even  fecal  vomit- 
ino-  has  been  observed.  ^  Sometimes  there  is  anuria,  and  the  gastric 
ejecta  will  be  found  to  contain  a  corresponding  amount  of  urea.  The 
amount  of  vomiting  and  urinary  excretion  often  alternate  in  close  rela- 
tion. In  another  form  the  esophageal  spasm  is  temporary  or  more  or 
less  prolonged  in  the  form  of  globus.  Tympanites  may  appear  in  asso- 
ciation with  contracture  of  the  abdominal  muscles,  and  cause  a  phantom 
tumor,  or,  if  attended  by  hyperesthesia,  the  appearances  suggest  peritonitis. 
Intestinal  spasms  are  of  frequent  occurrence  in  hysteria,  and  may  even 
produce  prolonged  obstipation  by  an  anorectal  contracture,  which  is  often 
attended  by  severe  pain  and  great  sensitiveness.  It  may  be  mistaken 
for  rectal  stricture. 

Urinary  Apparatus. — In  addition  to  the  anuria  and  partial  sup- 
pression of  the  urine  attending  or  alternating  with  hysterical  vomiting, 
and  the  discharge  of  large  quantities  of  limpid  urine  of  low  specific 
gravity  in  the  prodromal  period  of  the  attacks,  or  after  any  of  the  acci- 
dental crises  of  hysteria,  the  amount  and  relative  proportion  of  some  of 
the  urinary  constituents  may  be  greatly  modified.  Tourette  and  Catheli- 
neau  found  that  the  urine  of  hysterics  in  the  interparoxistic  periods  of 
their  disease  was  practically  normal.  Hysterical  storms  or  temporary 
accidental  crises,  such  as  convulsive  attacks  and  the  various  forms  of 
1  Bregman,  "Neurol.  Centralbl.,"  Oct.,  1901. 


HYSTERIA.  597 

hysterical  status,  like  rhythmical  spasms,  delirium,  or  trance,  presented 
a  marked  change  in  the  urinary  excretion.  There  is  (1)  a  notable 
diminution  in  the  fixed  residue ;  (2)  the  urea  is  reduced  about  one- 
third  ;  (3)  the  phosphates  are  decreased  about  one-half  of  the  normal 
output  for  twenty-four  hours.  Upon  examination  they  found  (4)  that 
the  normal  proportion  of  the  alkaline  to  the  earthy  phosphates  was 
altered.  Ordinarily,  it  is  in  the  ratio  of  alkaline  3  to  earthy  1,  but 
immediately  after  or  during  such  attacks  they  become  about  equal.  It 
is  necessary  to  secure  a  twenty-four-liour  collection  on  which  to  base 
such  estimates,  and  it  should  embrace  the  period  of  the  hysterical  storm. 
Further,  (5)  in  status  lasting  several  days  they  observed  that  the  dimi- 
nution of  urea  lessened  toward  the  end  of  the  attack,  and  as  it  reached 
the  normal  amount  the  status  yielded.  Although  any  of  the  points 
may  be  presented  in  other  than  hysterical  conditions  and  even  in 
epilepsy,  the  combination  of  the  first  four  may  be  taken  as  very  charac- 
teristic.     Many  hysterics  are  troubled  with  frequent  urination,  which  is 


■k..^. 


Fig.  264. — Dermographia  in  a  male  hysteric. 

especially  aggravated  if  the  mucous  surfaces  of  the  genitals  or  of  the 
bladder  are  hyperesthetic.  Mathieu  ^  and  Babinski  assert  that  polyuria 
is  generally,  if  not  always,  hysterical.  In  short,  that  diabetes  insipidus 
is  a  hysterical  manifestation. 

Hysterical  fever  may  be  continued,  remittent,  or  intermittent,  and 
usually,  if  not  always,  is  found  in  female  cases.  After  an  interval  of 
a  few  days,  or  perhaps  only  after  many  months,  it  may  disappear  sud- 
denly. The  temperature  may  attain  a  high  range — 105°  or  106° 
are  not  infrequent,  and  110°  and  higher  have  been  recorded. 
Usually  the  physical  state  shows  no  corresponding  febrile  disturbance, 
but  in  some  instances  the  tongue  is  heavily  coated,  there  is  headache, 
depression,  sweats,  and  general  phenomena  of  fever.  Emaciation  is 
very  unusual.  Commonly  hysterical  fever  is  unattended  by  other  hys- 
terical accidents,  but  it  may  be  associated  with  pulmonary,  meningeal, 
and  peritoneal  symptoms,  and  lead  to  mistakes.  The  intermittent 
1  "Prog,  med.,"  Feb.  18,  1899. 


598  NEUROSES. 

form  may  suggest  malaria.  In  the  diagnosis  of  hysterical  fever  all 
sources  of  infection  and  hidden  suppuration  must  be  carefully  in- 
vestigated. 

Trophic  and  Vasomotor  Accidents. — The  trophic  accidents  of 
hysteria  are  of  recent  recognition.  They  are  few  in  number,  and  are 
but  rarely  encountered  in  severe  degree.  On  the  skin  erythematous 
or  vesicular  eruptions  are  the  most  common  manifestation,  and  the 
vesicular  form  may  go  on  to  ulceration  and  produce  persistent  scars. 
Even  cutaneous  gangrene  has  been  recorded.  Cutaneous  hemorrhages 
in  the  form  of  bloody  sweats  have  followed  severe  emotional  disturb- 
ances. In  some  historical  cases  they  have  given  rise  to  the  stigmata  of 
the  crucifixion  or  been  attributed  to  the  finger-prints  of  the  devil. 
They  are  usually  preceded  by  great  pain  in  the  parts.  Bloody  tears 
and  bloody  discharges  from  the  mammae  or  from  the  lungs  are  of  a 
similar  nature.  Some  hysterics  show  transitory  periods  of  dermog- 
raphism. Neurotic  edema,  which  may  be  red,  blue,  or  white,  and  local 
asphyxias  similar  in  appearance  to  those  of  Raynaud's  disease,  may 
persist  for  many  days,  and  usually  ap- 
pear in  parts  otherwise  hysterically 
affected. 

The  hysterical  breast  is  of  rare  oc- 
currence, but  furnishes  a  source  of 
much  apprehension  and  misapprehen- 
sion. Suddenly,  or  within  a  few  hours, 
one  or  both  breasts  enlarge,  and  are 
sensitive,  painful,  and  hot.  The  skin 
may  even  be  reddened.  The  nipple  is 
turgid  and  sometimes  erect.    The  glands  -c-    o^-    xi   *   •   i      *     .  a 

o                                                                           c  Fig.  26o.— Hystencal  contracture    and 

are    firm  to  the    touch,  but    not    edema-  edema  of  the  hand,  lasting  several  months. 

,      ,        ,                         .   .                    .  Index-finger  not  affected.     Gauze   used   to 

tons,  and  the  hypersenSltlVeneSS  is  USU-  prevent  nails  cutting  into  palm. 

ally  extreme.  The  enlargement  may  last 

several  days  or  several  months,  and,  if  one-sided,  may  lead  to  suspicion 
■of  abscess  or  new  growth.  When  bilateral,  the  condition  has  sug- 
gested pregnancy,  especially  as  a  milky  fluid  may  ooze  from  the  nipples. 

Fibrotendinous  contractures  in  muscles  the  seat  of  persistent 
hysterical  contractures  have  already  been  noted.  Muscular  atrophy 
has  been  observed  by  a  number  of  reliable  observers.  It  has  its  seat 
in  the  muscles  of  a  paralytic  or  contracturecl  member,  and  rapidly 
develops.  Within  a  few  days  the  muscular  masses  may  lose  a  third  or 
a  half  of  their  volume.  The  condition  then  remains  stationary  for  a 
long  time,  and  finally  recovers.  There  is  a  quantitative  loss  in  elec- 
trical excitability  proportionate  to  the  muscular  shrinkage,  but  -the 
reaction  of  degeneration  does  not  occur. 

Course. — The  course  of  hysteria  is  essentially  chronic.  Sensory 
stigmata  have  been  known  to  persist  for  a  lifetime,  although  accidents 
had  long  ceased  to  occur.  It  should  be  looked  upon  as  a  mental  state 
which  is  likely  to  persist  when  once  established,  and  as  constituting  a 
real  disability,  which  may  be  partial  or  total.  The  various  accidents 
may  occur  transiently,  repeatedly,  or  persist  for  months  and  years,  and 


HYSTERIA.  599 

must  be  individually  considered  in  connection  with  each  case.  Under 
proper  management  hysteria  is  usually  a  managealjle  disease.  Many 
cases  (jet  instant  reliel' under  certain  mental  and  moral  influences. 

Prognosis  in  hysteria  is  clouded  by  the  probability  of  recurrence 
under  the  action  of  inciting  causes  that  otherwise  might  be  trivial  inci- 
dents. Many  patients  make  substantial  gain  and  consider  themselves 
Avell,  when  an  exhaustive  examination  discovers  numerous  persistent 
stigmata.  These  may  be  considered  subjective  recoveries.  It  is  excep- 
tional for  well-developed  cases  of  hysteria  to  regain  absolute  health. 
Children  and  youths  make  better  recoveries  than  older  subjects.  Major 
hvsteria  after  the  age  of  forty  presents  very  poor  prospects  of  com]ilete 
recession.  Many  of  the  accidents  of  hysteria  and  some  of  the  stigmata 
are  capable  of  instant  disappearence,  many  of  the  disabling  features 
are  easily  controlled  and  dissipated,  but  the  fact  remains  that  the  cura- 
bility of  hysteria  has  been  greatly  overstated. 

Diagnosis. — The  diagnosis  of  hysteria  loses  many  difficulties  if  it 
is  clearly  distinguished  from  neurasthenia,  emotional  disturbances,  and 
wilful  deceit  with  which  it  has  been  commonly  confounded.  They  have 
nothing  to  do  with  hysteria  properly  considered,  but  may  complicate  it. 
AVhile  hysteria  is  polymorphous,  and  may  mimic  all  other  maladies,  in 
that  very  fact  lies  its  detection.  There  is  in  it  always  an  excessive  or 
paradoxical  element.  No  disease,  when  well  developed,  is  so  distinctly 
marked  and  stigmatized.  The  most  reliable  and  consistent  features  in 
hysteria  are  the  mental  characteristics  and  the  psychic  stigmata. 
Next  in  frequency  and  importance  are  the  sensory  stigmata,  among 
which  the  disturbance  of  the  color-fields  by  contraction  and  inversion 
is  common  and  well-nigh  pathognomonic.  Anesthesias  in  islets  or 
geometrical  outlines  are  practically  demonstrative  of  hysteria.  The 
movability  or  motility  of  anesthetic  areas  under  various  influences  is 
found  in  hysteria  alone.  Among  the  motor  stigmata  the  contracture 
diathesis  and  the  ideational  loss  of  power  for  systematized  movements, 
as  shown  in  astasia  or  agraphia,  while  strength  is  normal  in  other 
respects,  declare  the  hysterical  state. 

Some  hysterical  accidents  are  diagnostic.  The  typical  hysterical 
seizure  should  be  mistaken  for  nothing  else.  In  the  partial  and  much 
more  commonly  encountered  seizures,  attacks  of  ecstasy,  of  sleep,  and 
of  somnambulation  are  very  distinctive.  A  careful  examination  of  the 
palsies  and  contractures,  taken  with  the  ordinarily  associated  and  usu- 
ally superimposed  sensory  stigmata,  should  disclose  their  hysterical 
nature.  The  rhythmical  spasms  are  the  property  of  hysteria  alone. 
The  tremors  must  be  deciphered  from  the  context  of  hysterical  mani- 
festations and  confirmed  by  the  exclusion  of  organic  processes.  The 
same  is  true  of  the  intestinal  accidents.  In  the  condition  of  the  urine 
during  and  after  paroxysmal  manifestations  we  have  a  valuable  index. 
Reduction  in  total  solids,  especially  in  urea  and  phosphates,  with  the 
inverted  proportion  of  alkaline  and  earthy  phosphates  is,  perhaps,  only 
found  in  hysteria. 

Once  the  suspicion  of  hysteria  is  entertained,  a  painstaking  examina- 
tion of  the  patient  should  confirm  or  banish  it.     The  greatest  danger 


600  NEUROSES. 

arises  from  failing  to  appreciate  the  limitations  of  hysteria  and  allowing 
its  presence  to  interrupt  careful  search  for  organic  disease  of  which  it 
may  be  a  secondary  expression.  Too  often,  when  hysteria  is  recognized, 
the  physician  is  content  to  attribute  every  symptom  and  complaint  to 
the  psychoneurosis.  Hysterics  may  have  phthisis,  Bright' s  disease, 
cerebral  hemorrhage,  typhoid  fever,  and  hip-disease,  as  well  as  other 
persons.  In  every  hysterical  case  the  individual  must  not  be  forgotten 
or  actual  disease  overlooked. 

Treatment. — Recognizing  in  hysteria  a  mental  disturbance  princi- 
pally, the  treatment  must  be  mainly  psychic.  This  point  of  view 
mav  at  once  strengthen  and  weaken  the  physician.  Unless  he  has  a 
clear  conception  of  the  power  of  mental  therapeutics,  he  is  likely  to  look 
upon  all  measures  as  mere  placebos  and  to  lack  faith  in  their  value. 
Not  confident  himself,  he  fails  to  inspire  confidence  in  the  hysterical 
patient.  The  game  is  lost  before  it  is  begun.  It  is  the  self-confidence 
of  the  charlatan  or  the  fanatical  belief  of  the  "  Christian  Scientist "  that 
now  sometimes  succeeds  when  well-informed  physicians  fail.  Expectant 
attention  and  hopeful  anticipation  have  cured  hysteria  in  all  ages,  and 
are  potent  measures  to-day.  Methods  are  usually  successful  in  propor- 
tion as  thev  are  novel  to  the  patient,  strike  the  fancy,  and  stimulate  the 
iraao-ination.  This  serves  in  itself  to  distract  the  hysteric  from  the  rut 
of  his  fixed  ideas,  and,  if  the  assurance  of  help  and  cure  is  added  and 
constantly  repeated  by  suggestion,  it  tends  to  supplant  the  morbid  con- 
dition. A  great  moral  impression  or  a  mental  shock  may  terminate 
hvsteria  at  once  or  may  greatly  aggravate  it.  Treatment  may  be 
considered  (1)  as  general,  applicable  to  all  manifestations  of  the  disease  ; 
and  (2)  special,  regarding  the  manifestations  of  individual  cases. 

General  Treatment. — The  first  consideration  is,  if  possible,  to 
decipher  the  fixed  idea  that  dominates  the  patient.  This  is  easily  done 
when  the  hysterical  syndrome  originates  in  some  serious  mental  storm 
or  personal  experience.  In  other  cases  it  can  be  inferred  from  the 
hysterical  manifestations,  and  occasionally  it  is  constantly  expressed  in 
some  worry  or  apprehension.  In  many  cases,  however,  it  is  a  subcon- 
scious idea.  It  may  have  arisen  even  in  a  dream,  or  it  may  be  so 
intangible  that  it  never  is  fully  formulated  in  the  patient's  conscious- 
ness. Sometimes,  from  motives  of  shame,  or  modesty,  or  morbid  con- 
scientiousness, it  is  studiously  Concealed. 

When  once  the  end  of  the  tangled  skein  is  in  the  physician's 
hands,  his  task  is  to  modify  or  destroy  the  fixed  idea,  and  thus  remove 
the  source  of  morbid  mentalization.  Too  often  family  and  friends 
support  the  patient's  morbid  view  and  exaggerate  the  gloomy  pros- 
pects, adding  fuel  to  the  flames  by  anxious  solicitude  and  thinly 
veiled  or  openly  expressed  fears.  In  the  highly  suggestible  con- 
dition of  hysteria  their  constant  presence  and  their  consciously  or 
unconsciously  reiterated  depressing  suggestions  counteract  all  possible 
good  at  the  hands  of  the  physician.  The  ver\'  locality  in  which  the 
disease  has  developed  constitutes  a  forcible  reminder  of  its  present  and 
prospective  woes.     Unless  the   surroundings,  companions,  and  visitors 


HYSTERIA.  601 

of  a  hysteric  can  be  absolutely  controlled,  it  is  usually  impossible  to 
manage  the  patient.  It  is  for  this  reason  that  isolation  and  separation 
from  everything  associated  with  the  patient's  morbid  past  is  usually  the 
first  and  most  essential  requirement  of  treatment.  Under  new  circum- 
stances the  statements  of  the  physician  regarding  the  trivial  nature  of 
the  dominant  idea  or  his  orders  to  dismiss  it  and  his  assurance  of  cure 
carry  a  weight  and  force  that  are  not  immediately  destroyed  bv  other 
more  constant  and  less  wholesome  influences.  The  very  fact  of  isola- 
tion is  a  profound  influence  that  can  readily  be  guided  into  a  hopeful 
and  helpful  channel.  A  visit  from  an  anxious  mother  or  solicitous 
friend  may,  in  a  few  minutes,  destroy  all  advantage  and  recall  the  morbid 
past  with  added  intensity.  This  plan  of  treatment  can  often  be  put  in 
the  form  of  the  AVeir  Mitchell  rest-cure,  and  requires  the  same  con- 
ditions already  indicated  in  the  treatment  of  neurasthenia  (p.  572). 
Mild  cases,  especially  in  the  young,  can  sometimes  be  w^ell  managed  by 
a  long  journey  with  a  sensible  and  not  too  sympathetic  companion,  or  by 
a  protracted  visit  to  friends  or  relatives  properly  informed  of  the  atti- 
tude they  should  maintain  toward  the  patient. 

Hypnotism  in  its  concentrated  form  is  a  dangerous  measure  and  only 
of  occasional  service.  In  the  hypnotic  state  the  patient  may  readily 
disclose  the  hidden  or  subconscious  idea,  and  it  may  at  once  be  attacked 
and  destroyed  by  countersuggestion.  In  the  same  way  progressive 
improvement  or  immediate  relief  from  the  various  conditions  present 
in  the  patient  may  be  suggested.  Hypnotism  may,  however,  precipi- 
tate a  latent  hysteria,  and  patients  hypnotized  for  the  removal  of  trivial 
hysterical  symptoms  have,  in  the  hypnotic  state  or  immediately  after  it, 
bloomed  out  in  all  the  manifestations  of  major  attacks  or  developed  pro- 
tracted paralyses  and  contractures.  In  other  cases  hysteria  restrained 
by  hypnotism  has  recurred  with  added  force  when  the  s^nces  were  dis- 
continued, and  Fere  goes  so  far  as  to  consider  hypnotism  but  a  transfor- 
mation of  hysteria.     It  should  be  held  as  a  last  resort. 

It  goes  without  saying  that  anemia  and  general  states  call  for  such 
remedies  as  are  ordinarily  beneficial,  and  local  disease  presents  exactly 
the  same  indications  as  in  non-hysterical  patients. 

Special  Treatment. — The  convulsive  attacks  can  frequently  be 
stopped  by  a  dash  of  cold  water,  by  a  sharp  command,  by  pressure  on 
hysterogenic  zones,  and,  if  other  means  fail,  by  inhalations  of  ether. 
Their  repetition  depends  upon  conditions  which  must  be  met  by  the 
general  measures  previously  indicated.  Paralyses  and  contractures  are 
among  the  most  permanent  accidents  when  once  established,  and  become 
actual  stigmata.  If  taken  early,  they  can  usually  be  managed.  Mas- 
sage, electricity,  and  repeated  assurances  of  their  early  cure  and  of  their 
insignificant  importance  is  usually  sufficient  if  the  friends,  in  the  way 
already  described,  do  not  defeat  these  measures.  After  a  long  duration 
they  may  require  the  full  isolation  treatment.  Contractures  of  years' 
standing  may  be  followed  by  fibrotendinous  contractions  only  amenable 
to  surgery.  Anesthesias  and  hyperesthesias  can  be  modified  by  a  num- 
ber  of  influences  of  the   esthesioffcnic  sort.      Faradic  and  Franklinic 


602  NEUROSES. 

electricity  often  act  very  readily  to  reduce  and  completely  dissipate  the 
field  of  disturbed  sensation.  Various  objects,  metallic,  wooden,  etc., 
active  or  inert  magnets,  have  the  same  influence.  It  is  all  a  matter  of 
concentrating  the  fixed  and  hopefully  expectant  attention  upon  the 
parts.  In  the  same  way  these  measures  are  useful  in  the  palsies  and 
contractures.  Spinal  irritation,  so  called,  when  once  well  marked, 
usually  requires  the  isolation  and  rest  treatment,  but  sometimes  the 
actual  cautery  or  flying  blisters,  or  other  heroic  and  hence  impressive 
measures,  succeed  in  removing  the  hypersensitiveness.  Aphonia  and 
mutism  require  treatment  of  a  similar  sort.  A  faradic  electrode  intro- 
duced into  the  larynx  or  pharyngeal  cauterization  has  succeeded  almost 
instantly  in  some  cases,  but  lasting  benefit  usually  follows  persistent  and 
repeated  suggestion  of  steady  improvement,  coupled  with  various  sug- 
gestive manipulations  of  the  parts.  Laryngeal  sj)asm  and  hysterical 
cough  or  sneezing,  or  diaphragmatic  spasms,  generally  can  be  interrupted 
by  having  the  patient  or  a  nurse  forcibly  pull  on  the  protruded 
tongue.  Laryngeal  spasm  in  rare  instances  may  require  anesthesia  or 
even  tracheotomy,  but,  fortunately,  apnea  is  commonly  followed  by 
relaxation  of  the  spasm.  Dysphagia  from  esophageal  spasms  is  often 
relieved  by  passing  the  stomach-tube  and  demonstrating  the  permea- 
bility of  the  gullet.  Vomiting  is  sometimes  benefited  by  lavage  of  the 
stomach  and  the  mechanical  introduction  of  food,  but  assurance  of 
improvement  and  suggestion  must  be  added  to  all  these  measures. 

Finally,  it  is  the  physician  who  is  most  sure  of  himself  and  of  his 
diagnosis  and  has  a  distinct  idea  of  the  mental  side  of  hysteria  who 
best  succeeds  with  general  or  special  treatment. 


CHAPTER  VII. 
EPILEPSY. 


Epilepsy  has  been  the  subject  of  medical  description  since  the 
earliest  times.  It  was  known  to  the  ancients  as  the  sacred  disease, 
morbus  sacer.  In  colloquial  English  it  is  called  the  "  falling  sickness." 
Its  most  characteristic  manifestation  shows  forth  in  the  derivation  of 
the  name  "  epilepsy,"  which  implies  being  seized  upon.  The  seizing 
has  been  variously  attributed  to  mythological  deities,  to  the  possession 
of  devils,  and  to  vapors  and  humors  arising  in  the  body.  Focal  epi- 
lepsy, or  Jacksonian  epilepsy,  resulting  from  cerebral  injury  or  disease, 
may  be  omitted  from  the  present  consideration.  Epileptoid  attacks  arising 
from  alcohol,  lead,  and  uremia,  and  the  eclampsia  of  parturients  and 
children,  have  no  necessary  relation  to  the  epilepsy  now  in  question. 
Epilepsy  can  scarcely  be  considered  a  distinct  disease.  It  is  a  syn- 
drome of  nervous  and  mental  symptoms  appearing  under  a  variety  of 


EPILEPSY.  603 

pathological  states.  In  many  instances  it  is  associated  ^^•ith  morpho- 
loo'ieal  cellnlar  changes  in  the  cortex.  In  as  many  or  more  cases  the 
anatomical  basis  still  escapes  detection.  So  conunonly  is  epilepsy  pre- 
sented by  neuropathic  and  psychopathic  strains,  and  in  those  physically 
or  mentally  defective,  that  in  itself  it  may  be  considered  a  presumptive 
indication  of  degeneracy.  It  is  statistically  proven  that  there  is  more 
tlian  one  epileptic  for  every  four  hundred  of  the  population  in  this  country. 

Etiology. — Heredity  plays  a  very  important  part  in  the  causation 
of  epilepsy.  Arthritis,  sypliilis,  phthisis,  inebriety,  insanity,  and  neu- 
roses are  common  in  the  antecedents.  Epilepsy  appears  frequently  in 
succeeding  generations,  and  may  descend  directly  from  parents  to  chil- 
dren, but  is  more  likely  to  be  iudirectly  propagated  by  way  of  collateral 
branches.  The  heredity  is  more  often  by  transformation  from  other 
neuropsychic  disease.  Thus,  hysteria,  epilepsy,  and  idiocy  may  follow 
in  successive  generations.  Epilepsy  among  cousins  is  more  frequent 
than  among  brothers  and  sisters,  where,  however,  various  neuropathic 
equivalents  are  frequently  encountered.  Consanguinity  plays  no  part 
unless  it  brings  together  individuals  of  similar  nervous  or  mental  defect. 

Epilepsy  may  appear  at  any  age,  but  it  is  distinctly  uncommon  for 
it  to  commence  after  the  age  of  thirty.  Epileptoid  attacks  after  that 
age  should  always  awaken  a  suspicion  of  gross  organic  brain  disease. 
Syphilis  is  the  usual  cause  of  such  seizures  from  thirty  to  forty-five ; 
after  forty-five  we  encounter  the  degenerations  of  senility,  vascular 
changes  and  accidents.  The  very  great  majority  of  cases  of  epilepsy 
develop  under  twenty  years  of  age,  and  the  pubescent  period,  between 
twelve  and  seventeen,  contains  the  greater  proportion  of  them.  Very 
frequently  epilepsy  begins  in  infancy.  Convulsions  during  the  first  and 
second  dentitions,  incited  by  any  febrile,  septic,  or  toxic  cause,  may  be 
followed  by  epileptic  attacks  at  puberty.  In  some  cases  beginning  as 
eclamptic  attacks  in  infancy  or  early  childhood,  epilepsy  follows,  with 
more  or  less  periodical  attacks  from  that  time.  Some  families  present 
numerous  deaths  from  infantile  convulsions,  and  epilepsy  sometimes 
develops  in  those  who  escape.  Nocturnal  enuresis,  pavor  nocturnus, 
and  epilepsy  may  appear  in  the  same  case,  apparently  replacing  one 
another.  It  is  necessary  to  carefully  exclude  from  this  consideration  that 
large  number  of  cases  in  which  cerebral  injury  is  present  or  brain  defect 
arising  from  intra-uterine,  birth,  or  postnatal  causes.  Such  instances 
usually  present  evidence  of  cerebral  lesions  in  some  form  of  palsy,  and 
are  considered  in  part  iii.     The  two  sexes  are  about  equally  aiFected. 

Inciting  Causes. — The  alleged  inciting  causes  of  epilepsy,  by 
their  number  and  relative  harmlessness  in  the  majority  of  individuals, 
reinforce  the  presumption  of  a  necessary  predisposing  defect,  in  the 
field  of  which  they  become  active.  The  hereditary  considerations,  the 
usual  evidence  of  degeneracy,  and  the  common  onset  of  the  disease  at 
developmental  epochs  all  speak  of  a  vicious  organization  unequal  to 
the  shocks  of  ordinary  life  and  the  demands  of  growth.  In  some 
cases,  however,  it  is  impossible  to  fix  upon  any  predisposing  state. 

Toxic  agents,  such  as  alcohol,  lead,  mercury,  tobacco,  chloroform, 
ether,  morphin,  cocain,   etc.,  have  been  accused  of  inciting  epilepsy. 


604  NEUBOSES. 

Alcohol  is  certainly  competent  to  do  so.  The  first  fit  may  follow  a 
drinking  bout.  Other  toxic  conditions  arising  from  the  intestinal  tract 
or  due  to  defective  elimination  through  the  kidneys  may  act  as  inciting 
causes.  The  in/ectious  diseases,  such  as  the  exanthemata,  may  furnish 
the  starting-point  for  epilepsy.  Typhoid  fever  is  causative  in  some 
instances.  Syphilis  may  be  causally  related  to  epilepsy  in  various  ways  : 
(1)  As  a  hereditary  factor;  (2)  through  the  malnutrition  of  the  sec- 
ondary period  ;  (3)  by  local  encranial  disease ;  and  (4)  Fournier  thinks 
there  is  a  peculiar  syphilitic  variety  of  epilepsy  appearing  late  in  the 
luetic  history.  Head  injuries  may  produce  focal  epilepsy,  but  sometimes 
set  up  the  common  form  of  the  disease.  Reflex  irritations  due  to  nasal 
growths,  intestinal  worms,  pelvic  disease,  genital  abnormality  or  disease, 
masturbation,  and  eye-strain  are  occasionally  sufficient  to  provoke  epi- 
leptic attacks  and  to  cause  their  repetition.  Sensitive  scars,  decayed 
teeth,  and  ingrowing  toe-nail  have  also  been  brought  into  this  list.  In 
fact,  any  local  ])eripheral  cause  of  constant  nerve-fag  may,  in  those  of 
unstable  organization,  serve  to  upset  the  nervous  apparatus.  Physio- 
logical states,  like  menstruation  and  childbirth,  may  incite  epileptic 
attacks  in  those  predisposed.  In  female  epileptics,  the  menstrual 
periods  are  very  frequently  the  occasion  of  attacks.  3Ientol  shocks, 
particularly  fright,  may  cause  the  first  fit.  Some  epileptics  have  a  fit 
upon  the  incidence  of  any  emotional  disturbance. 

Pathology. — It  would  be  impossible  within  reasonable  limits  to 
give  the  numerous  theories  that  have  been  advanced  regarding  the 
nature  of  epilepsy,  or  to  discuss  at  length  the  various  locations  assigned 
the  morbid  action  resulting  in  the  fits.  Suffice  it  to  say  that  the 
presence  of  mental  symptoms,  sometimes  the  limitation  of  the  attack 
to  unconsciousness  alone,  the  experimental  demonstration  of  cortical 
excitability,  the  usual  organic  basis  of  Jacksonian  fits,  the  recent  find- 
ings of  changed  cortical  structures  in  some  cases,  and  a  recognition  of 
the  supremacy  of  the  cell  in  the  doctrine  of  the  neuron  theory,  all  com- 
bine to  declare  epilepsy  a  disease  of  the  cerebral  cortex. 

It  must  be  admitted  that  at  present  the  most  careful  search  fails  in 
many  cases  to  detect  any  histological  changes  known  to  be  morbid. 
This  is  only  another  way  of  stating  our  ignorance  of  certain  patho- 
logical processes  and  the  limitations  of  present  methods  of  research. 
When  a  patient  dies  as  the  result  of  repeated  convulsions,  venous  and 
sinus  engorgement,  minute  hemorrhages,  and  more  or  less  extensive 
cerebral  ecchymoses  merely  evidence  the  recent  paroxysms.  Lesions 
of  longer  standing  have  been  frequently  found,  such  as  meningo-en- 
cephalitis,  widely  disseminated  tuberous  sclerosis  in  the  cortex  and  the 
great  ganglia,  and  diffuse  sclerosis  of  the  convolutions.  Much  impor- 
tance was  once  attached  to  such  hypertrophic  sclerosis  affecting  the 
cornu  ammonis  or  appearing  in  the  bulb.  Chaslin,  Fere,  and  many 
others  have  repeatedly  found  neuroglial  proliferation.  Bloch  and 
Marenesco  have  described  vascular  and  perivascular  changes  in  the 
cortex.  Van  Giesen  has  demonstrated  changes  in  the  large  pyramidal 
cells  of  the  cortex  and  in  the  neuroglia  in  two  cases  in  which  portions 


EPILEPSY.  605 

of  the  cortex  were  removed  by  operation.  Bleuler/  in  twenty-six 
epileptic  brains,  found  a  definite,  wide-spread  hypertrophy  of  the 
neuroglial  bundles  lying  between  the  pia  and  outermost  nerve- 
bundles.  This  change  was  not  proportional  to  the  severity  or  duration 
of  the  disease  or  relative  to  the  mental  degradation  of  the  patients.  In 
fifty-four  non-epileptic  brains  similar  changes  were  not  found.  Ohl- 
macher  ^  draws  prominent  attention  to  persistent  thymus  and  enlarged 
intestinal  glands. 

Symptoms. — The  most  striking  symptoms  of  epilepsy  are  the 
"attacks"  or  fits  and  their  modifications  and  equivalents.  Of  equal 
importance  are  the  postepileptic  states  and  the  mental  and  physical 
conditions  of  epileptics. 

Epileptic  Attacks. — Prodromes  and  Aurse. — Many,  but  by  no 
means  all,  epileptics  have  some  distant  or  immediate  premonition  of 
the  attack.  Friends,  nnrses,  and  attendants  upon  epileptics  often  learn 
to  anticipate  an  attack  by  temperamental  or  facial  changes  that  are 
unnoticed  by  the  patients  themselves.  These  may  be  present  several 
hours,  or  even  several  days,  before  the  convulsive  explosion.  Fore- 
runners of  a  motor  sort  are  grinding  of  the  teeth  in  sleep,  twitching  of 
the  eyelids,  face,  or  extremities,  tremors,  and  restlessness.  Some  epi- 
leptics complain  of  tingling  in  the  extremities  or  on  the  surface  of  the 
body  ;  others  have  peculiar  sensations  on  the  tongue  or  in  the  nose,  a 
tickling  of  the  palate,  or  disturbances  of  smell  or  taste.  Others  have 
photophobia  or  brilliant  muscse.  Ringing  in  the  ears,  genital  excite- 
ment, respiratory  oppression,  vague  discomfort,  mental  stimulation  or 
depression,  unusual  irritability  or  gaiety,  are  some  of  the  various  pre- 
monitory conditions.  Some  patients  look  unusually  pale  ;  others  present 
a  suffused,  puffy  countenance  ;  and  temporary  erythematous  and  urticarial 
eruptions  have  been  seen.  Much  as  these  more  or  less  prolonged  pre- 
monitory conditions  vary  among  themselves,  they  are  comparatively 
uniform  and  constant  for  a  given  case. 

The  aura  is  the  particular  motor,  sensory,  or  psychic  feature  that 
immediately  announces  the  attack,  and  may  be  considered  its  initial 
symptom.  In  some  instances  it  represents  an  abridged  attack.  It  may 
recur  for  years  unrecognized,  until  a  fully  developed  fit  indicates  its  true 
character.  An  aura  of  some  sort  occurs  in  fully  one-half  of  all  cases 
of  epilepsy.  Motor  aurcE  may  consist  in  a  sudden  limited  muscular 
contraction  or  tremor,  similar  to  the  signal  symptom  of  Jacksonian  fits, 
but  of  only  momentary  duration.  Automatic  movement,  and  even  a 
series  of  coordinate  acts,  may  introduce  the  generalized  attack.  A 
patient  scratches  at  the  pit  of  the  stomach,  or  winks  his  eyes,  or 
moistens  his  lips  with  his  tongue,  or  makes  a  few  swallowing  efforts, 
starts  forward  or  backward,  rotates  upon  his  vertical  axis,  coughs  spas- 
modically, springs  up,  or  rolls  his  eyes  to  one  side,  following  with  his 
head  and  body.  Unconsciousness  at  once  follows,  and  the  full  fit  occurs. 
Many  epileptics  have  sensory  aarce.     A  peculiar  sensation  is  described, 

1  "  Mlinch.  med.  Woclieca.,"  No.  33,  1895. 

2  ''B„n   Ohio  Hosp.  for  Epileptics,"  1898. 


606  NEUROSES. 

commencing  in  tlie  feet  or  anywhere  in  the  extremities,  or  in  the  abdo- 
men, especially  at  the  pit  of  the  stomach.  It  mounts  upward,  and  con- 
sciousness usually  fails  as  it  reaches  the  upper  part  of  the  chest  or  the 
neck  and  head.  In  some  instances  it  strongly  suggests  the  globus  of 
hysteria.  One  patient  describes  it  as  a  "  nagging  feeling,"  and  it 
usually  is  of  an  indefinite  and  indescribable  sort.  Visual  and  auditory 
sensations  are  the  most  frequent  of  those  that  relate  to  the  special 
senses.  Those  of  taste  and  smell  are  very  rare.  Some  epileptics  hear 
certain  sounds  of  a  pleasant  or  startling  sort ;  sometimes  it  is  a  distinct 
voice.  Others  describe  everything  as  turning  black  or  dark  before 
their  eyes  ;  some  have  phosphenes  or  bright  flashes ;  and  in  exceptional 
instances  a  definite  picture  is  presented,  such  as  that  of  persons  or 
animals,  which  may  rapidly  approach  or  recede. 

Jackson  first  called  particular  attention  to  the  psychiG  aurce,  which 
are  as  vague  and  varied  as  those  of  a  motor  and  sensory  character.  A 
sudden  recollection  or  the  instantaneous  review  of  a  lifetime,  a  certain 
fixed  idea  or  doubt,  may  announce  the  convulsion.  Sometimes  it  is  a 
rapidly  growing  mental  depression,  a  fervor,  a  feeling  of  mental  exal- 
tation or  weakness,  irritable  impulses,  gaiety,  rage,  or  quarrelsomeness. 

Another  group  of  aurse  are  called  viscei-al,  but  are,  for  the  most  part, 
sensory  or  motor  manifestations  referred  to  the  various  organs.  Pre- 
cordial pain,  violent  cardiac  palpitations,  respiratory  anguish,  laryngeal 
spasm,  weight  at  the  pit  of  the  stomach,  vomiting,  colics,  and  sudden 
imperative  demands  to  evacuate  the  bladder  or  bowels  are  the  principal 
ones.  Cerebral  aurce,  such  as  sudden  pain  in  the  head,  vertigo,  stam- 
mering, and  paraphasia,  have  been  noted. 

Lewis  has  noted  an  elevation  of  body  temperature  during  the  aura, 
and  Voisin  has  observed  increased  temperature  in  the  limbs  in  which 
the  aura  originated.  Fere  and  Franck  have  noted  an  increase  of 
arterial  tension  before  the  fit,  and  the  writer  has  obtained  a  sphygmo- 
gram  showing  the  same  thing.  All  these  considerations  indicate  that 
the  aura  is  of  cerebral  origin,  and  serve  to  indicate  the  portion  of  the 
brain  most  at  fault,  just  as  does  the  original  symptom  in  Jacksonian 
fits.  They  should  assist  in  mapping  out  the  functions  of  the  so-called 
cortical  areas  of  latent  lesions. 

Epileptic  fits  vary  greatly  in  different  cases,  and  usually  a  patient 
presenting  severe  convulsions  also  has  slight  or  abortive  attacks.  We 
may  consider  (1)  the  complete  attack,  (2)  the  incomplete  attacks,  and 
(3)  the  equivalents  of  epileptic  attacks. 

The  complete  convulsion,  preceded  by  an  aura  or  not,  comes  on 
suddenly,  consciousness  and  sensibility  are  instantly  lost,  and  the  patient 
falls.  The  fit  presents  three  distinct  periods  :  (1)  one  of  tonic  conviil- 
sion  ;  (2)  one  of  clonic  convulsions  ;  and  (3)  a  period  of  stertor. 

The  tonic  stage  opens  suddenly,  with  all  the  muscles  of  the  body 
in  tetanic  rigidity.  It  results  that  the  patient  not  only  falls,  but  is  fre- 
quently violently  thrown  down.  At  the  same  time,  the  sudden  tetanic 
muscular  grasp  of  the  thoracic  cage  and  the  fixation  of  the  laryngeal 
apparatus  give  rise  to  a  cry  that  is  practically  never  verbal.     Some- 


EPILEPSY.  607 

times  it  is  a  shriek  ;  more  often  it  is  an  expiratory  gutteral  noise.  The 
face  is  at  first  pale,  bnt  rapidly  becomes  congested  and  cyanotic,  because 
respiration  is  inhibited.  Tlie  eyes  are  fixed,  often  turned  up  or  to  one 
side  or  convergent,  and  the  pupils  are  rigidly  dilated.  Minute  vascular 
ruptures  in  the  skin,  mucous  membrane,  and  conjunctiva  often  occur. 
It  is  probable  that  similar  vascular  accidents  take  place  in  the  internal 
viscera  and  in  the  brain.  If  the  hand  be  placed  on  the  tonically  con- 
tracted muscles,  a  thrill  or  vibratory  impulse  will  be  detected,  such  as  is 
occasioned  by  excessive  voluntary  efforts.  The  tonic  period  is  one  of 
apnea,  and  only  lasts  one  to  two  minutes  at  most.  It  may  last  only  a 
few  seconds.  The  tongue  is  frequently  thrust  between  the  teeth,  and 
may  be  lacerated.  The  head  may  be  slightly  turned  or  retracted,  the 
trunk  is  rigid  and  usually  straight,  the  upper  extremities,  flexed  at  the 
elbows,  are  held  close  to  the  trunk,  the  fists  are  clenched,  or  the  fingers 
may  be  made  into  a  cone  or  spread  by  the  interossei.  The  lower  ex- 
tremities are  usually  rigidly  extended.  It  is  at  this  stage  usually  that 
the  spasm  of  the  abdominal  muscles  expels  the  contents  of  the 
bladder,  sometimes  those  of  the  rectum.  The  vascular  strain  is 
extreme. 

The  clonic  period  is  in  some  sense  a  continuation  of  the  tonic 
stage.  The  muscles  relax,  and  again  suddenly  contract.  The  limbs, 
body,  face,  and  all  movable  parts  are  agitated  by  the  sudden  sharp 
twitchings,  which  cause  the  face  to  grimace  horribly,  the  jaws  to  grind 
together,  often  lacerating  the  tongue  and  cheeks,  the  eyes  to  jerk  in  their 
sockets,  the  air  to  be  noisily  forced  in  and  out  of  the  chest,  churning 
the  saliva  in  the  mouth  and  throat  and  forcing  it  through  the  teeth  and 
lips  in  a  bloody  foam.  'The  arms,  legs,  and  head  beat  against  the 
ground.  The  clonic  movements,  at  first  rapidly  repeated,  gradually 
become  less  frequent,  but  maintain  their  force  and  vigor  to  the  very  last 
movement.  The  respiration,  dominated  by  the  clonic  spasm,  is  ineffi- 
cient ;  the  asphyxia  and  cyanosis  persist ;  the  cardiac  movements  are  pre- 
cipitate ;  the  arterial  tension  is  intense.  This  stage  lasts  from  one  to  five 
minutes,  and  terminates  in  full  relaxation,  in  which  the  bladder  and 
rectum,  if  not  emptied  in  the  tonic  period,  may  allow  their  contents  to 
escape.  The  body  and  face  are  covered  with  perspiration,  the  tempera- 
ture mounts  two  or  three  degrees  Fahrenheit.  The  clonic  movements 
may  be  bilaterally  synchronous,  but  have  no  suggestion  of  purpose,  and 
are  unmethodical  and  incoordinate. 

Tlie  Period  of  Sfertor. — The  relaxation  in  which  the  clonic  stage 
ends  is  usually  marked  by  deep  stertorous  breathing  and  continued  un- 
consciousness. The  patient  lies  inert,  just  as  the  convulsion  left  him, 
profoundly  comatose,  and  may  perish  at  this  time,  smothered  by  the  bed- 
clothes or  by  similar  mishap.  After  a  few  minutes,  perhaps  after  a 
half  hour  or  more,  he  opens  his  eyes  and  regains  partial  control  of 
himself,  without  any  knowledge  of  what  has  happened  during  the 
attack.  If  the  attack  take  place  during  the  night,  the  stertorous  period 
may  gradually  merge  into  natural  sleep,  and  the  patient  may  be  entirely 
unconscious  of  the  occurrence  of  the  fit.     Usually  the  fit  leaves  the 


608  NEUROSES. 

patient  more  or  less  confused,  fatigued,  sore,  strained,  and  subdued  for 
several  hours  or  for  a  day  or  two. 

While  the  typical  fit  presents  all  of  these  symptoms,  it  may  be  infi- 
nitely modified.  The  tonic  period  may  be  instantaneous  only.  The 
clonic  movements  may  be  confined  to  the  face,  upper  extremities,  or 
lower  limbs.  The  cry,  urination,  stertor,  or  bitten  tongue  may  any  or 
all  be  lacking.  The  convulsion  may  be  most  marked  on  one  side,  and, 
indeed,  exact  symmetry  is  uncommon.  The  only  constant  feature  is 
disturbed  consciousness,  but  unconsciousness  does  not  in  itself  constitute 
a  fit,  though  it  may  practically  constitute  an  equivalent. 

Epileptic  attacks  often  occur  during  the  night,  and  in  some  instances 
only  during  sleep,  giving  rise  to  the  clinical  variety  called  nocturnal 
epilepsy,  which  may  last  for  years  without  being  suspected.  Fits  are 
likely  to  occur  just  as  the  patient  is  getting  to  sleep,  or  just  as  he  is 
awakening  in  the  morning.  They  may  be  induced  by  emotion,  espe- 
cially fright.  Fatigue,  coitus,  menstruation,  and  child-birth  may  pro- 
voke them.  In  most  cases,  however,  they  take  place  without  adequate 
traceable  cause.  Some  patients  have  them  very  frequently,  and  with 
considerable  regularity  ;  others  have  them  at  irregular  intervals ;  and 
others  may  have  but  two  or  three  during  a  lifetime.  In  aggravated 
instances  they  occur  in  groups,  several  taking  place  within  a  day.  Such 
groups  frequently  follow  an  interval  more  than  usually  prolonged,  or 
succeed  a  period  of  bromid  repression. 

Occasionally,  the  patient,  without  recovering  consciousness,  has  fit 
after  fit,  and  in  this  way  a  series  of  hundreds  may  occur.  This  consti- 
tutes the  status  epileptiGUS,  the  gravest  form  of  epileptic  paroxysm.  It 
consists  of  (1)  a  period  of  incessant  convulsions,  and  (2)  of  a  period  of 
prostration  and  collapse  ;  but  sometimes  death  occurs  in  the  convulsive 
stage.  Usually,  after  the  fits  have  continued  for  several  hours,  or  even 
for  several  days,  they  become  less  severe,  and  finally  cease,  and  collapse 
ensues.  During  the  convulsions  the  temperature  may  reach  104°  or  105°, 
and  even  rise  higher,  until  death  occurs.  The  individual  fits  of  the 
status  epilepticus  are  rarely  of  the  severest  variety.  The  stupor  is 
punctuated  more  or  less  regularly  by  convulsive  attacks  of  moderate 
force,  and  the  status  may  even  be  made  up  of  the  limited  attacks  of  the 
incomplete  variety,  such  as  vertigos.  The  collapse  of  epileptic  status 
may  be  so  profound  as  to  reach  a  fatal  ending. 

Incomplete  Attacks. — Petit  Mai. — Fractional  epileptic  attacks 
present  an  endless  variety,  of  which  only  a  few  of  the  common  forms  can 
be  indicated.  Almost  any  part  of  the  full  attack  as  previously  described 
may  alone  constitute  the  limited  seizure.  Very  frequently  the  disease 
presents  an  aura  and  the  attack  aborts.  This  may  occur  repeatedly, 
even  for  years,  before  the  major  seizures  develop.  Such  warnings  may 
occur  in  the  intervals  between  the  full  attacks  or  after  they  cease,  if  the 
disease  subside  spontaneously  or  under  treatment.  A  large  number  of 
cases  present  vertiginous  attacks.  The  patient  suddenly  loses  conscious- 
ness and  falls,  or  nearly  falls.  There  is  usually  slight  twitching  of  the 
face,  or  perhaps  only  a  little  quivering  about  the  eyes  or  mouth,  or  a 


EPILEPSY.  609 

deviation  of  the  head  and  eyes,  which  may  pass  unperceived.  Ahnost 
instantly  the  patient  recovers  himself,  but  may  feel  weak  and  faint.  In 
other  instances  the  patient  falls  heavily,  but  clonic  movements  and 
stertor  do  not  develop.  Again,  the  patient  may  fall,  and  become  at  once 
comatose  and  stertorous,  as  in  apoplexy. 

Of  great  interest  are  the  attacks  marked  mainly  by  a  momentary  loss 
or  disturbance  of  consciousness.  The  face  may  suddenly  pale  and  the 
eyes  look  vacant.  Whatever  is  being  done  is  interrupted,  and  imme- 
diately resumed.  The  patient  ordinarily  has  no  knowledge  of  anything 
unusual  having  occurred.  In  talking  he  suddenly  stops,  looks  absent- 
minded,  and  takes  up  the  sentence  where  it  was  broken.  A  musician 
may  pause  one  or  two  bars,  and  continue.  At  table  the  cup  is  poised 
half  way  to  the  mouth,  etc.  In  other  instances  a  little  twitching  of  the 
face  is  noticed,  or  the  patient  drops  or  throws  whatever  he  has  in  his 
hand,  and  usually  there  is  momentary  rigidity  during  the  brief  uncon- 
sciousness. In  some  instances  a  few  words  are  muttered,  or  a  little 
saliva  dribbles  from  the  mouth,  and  in  such  attacks  the  escape  of  urine 
is  far  from  infrequent. 

In  rare  instances  the  patient,  under  an  irresistible  impulse,  rapidly 
walks  or  violently  runs  for  a  few  moments  in  an  automatic,  unconscious 
way,  and  may  fall  finally  in  a  fit,  or  may  recover  consciousness  without 
an  intervening  convulsion  ;  or  after  a  fit  a  patient  may  suddenly  run  for 
some  distance  {epilepsia,  processiva).  Attacks  of  stertorous  sleep  have 
been  recorded,  into  which  the  patient  falls  at  intervals,  and  during 
which  he  can  not  be  aroused.  These  may  alternate  with  convulsive 
attacks  or  may  be  replaced  by  them.  Attacks  of  generalized  or  localized 
trembling,  local  spasm,  and  salaam  spasms  may  constitute  the  epileptic 
paroxysm.  As  before  said,  the  only  constant  feature  in  epileptic 
attacks  is  a  disturbance  of  consciousness  during  the  period  of  the  attack. 
Ceni  1  has  observed  sudden  falling  of  body-temperature  for  about  an 
hour,  amounting  to  several  degrees,  sometimes  recurring  several  times  a 
day,  and  apparently  constituting  an  epileptic  equivalent. 

Psychic  Equivalents  of  the  Epileptic  Attack. — Instead  of 
epileptic  attacks  of  the  ordinary  kind,  or  in  alternation  with  such,  or  as 
a  repeated  prelude  to  the  major  convulsions,  or  immediately  following 
the  fits,  we  may  have  a  variety  of  acute  mental  disturbances.  Epilep- 
tics may  unconsciously,  automatically,  and  with  apparent  purpose  per- 
form a  number  of  coordinate  acts.  Homicidal,  obscene,  or  pyromaniac 
acts  may  thus  be  done  by  epileptics,  or  intricate  manoeuvers,  such  as 
require  the  use  of  tools,  may  be  accomplished.  Subsequently,  as  a  rule, 
they  have  no  knowledge  of  such  acts.  The  procursive  fit  may,  in  a  sort 
of  status,  be  prolonged  so  that  the  patient  may  make  long  flights,  or,  in 
a  less  violent  way,  make  journeys  of  several  hours'  or  several  days' 
duration,  during  which  the  conduct  is  so  natural  as  to  attract  no  notice. 
Self-consciousness  usually  is  rather  abruptly  restored,  and  they  are 
astonished  to  find  themselves  at  a  distance  from  home,  M'ith  an  interven- 
ing blank  period  of  time.      Sudden  wild,  maniacal  outbursts,  in  which 

1  "Centralbl.  f.  Nervenh.  u.  Psychiat.,"  Oct.,  1900. 
39 


610  NEUBOSES. 

the  patient  may  be  destructive  and  dangerous  to  others,  are  encountered, 
and  these  may  terminate  suddenly  or  be  protracted  for  several  days, 
attended  by  great  excitement,  a  high  pulse  and  temperature,  and  subse- 
quent collapse.  Sometimes  such  attacks  are  stopped  by  a  fit,  or  they 
may  succeed  a  severe  convulsion,  or  they  may  take  the  place  of  the 
convulsion.  Epileptic  automatism  may,  in  a  static  form,  last  days 
and  weeks,  during  which  the  patient  conforms  naturally  to  his  sur- 
roundings, but  subsequently  has  little  or  no  knowledge  of  the  auto- 
matic period. 

Postparoxysmal  Phenomena. — As  physicians  in  practice  rarely 
have  the  opportunity  of  seeing  the  patients  in  epileptic  attacks,  a 
knowledge  of  the  postparoxysmal  phenomena  is  important.  As  a 
result  of  the  cortical  exhaustion,  a  number  of  transitory  symptoms 
follow  the  usual  seizure.  Tremor,  paresis,  disturbances  of  sjDeech,  of 
general  sensibility,  and  of  the  special  senses  have  sometimes  been 
observed ;  the  muscular  strength  is  commonly  reduced,  the  knee-jerks 
are  diminished  or  abolished,  and  muscular  tone  is  lessened.  Several 
attacks,  repeated  within  a  few  hours,  lead  to  an  appreciable  loss  of  body 
weight.  The  urine,  even  after  a  single  attack,  shows  an  increase  of 
phosphates,  particularly  of  the  earthy  phosphates,  and  of  the  nitro- 
genous constituents.  The  temperature  is  commonly  elevated  a  degree 
or  two.  This  may  occur  even  in  petit  mal,  and  has  been  noted  in  the 
brain  itself  by  Mirto.  ^  The  toxicity  of  the  urine  is  increased,  and 
Agostini  ^  finds  the  gastric  juice  has  toxic  properties.  These  properties 
are  most  marked  just  before  and  after  a  fit,  and  are  proportionate  to  the 
intensity  of  the  attack.  Vomiting  after  an  attack  is  not  uncommon 
and  almost  invariably  causes  the  fit  to  be  attributed  to  errors  of  diet, 
which  is  sometimes  the  case.  Cabitto  ^  claims  that  the  sweat  of  epilep- 
tics is  hypertoxic  previous  to  the  fits,  and  urges  the  use  of  hot  baths 
in  the  treatment  of  the  disease,  asserting  good  results  from  their  em- 
ployment. The  special  toxicity  of  the  excretions  in  epilepsy  is  not 
proven.  The  arterial  pressure  is  reduced,  crises  of  polyuria,  diarrhea, 
sweating,  and  salivation  may  be  encountered.  The  presence  of  petechial 
ecchymoses,  the  bitten  tongue,  the  voided  urine,  or  fecal  discharge  is  to 
be  noted.  Ordinarily,  there  is  mental  hebetude  and  sluggishness,  a 
tendency  to  languor,  and  a  desire  to  sleep.  Headache  is  usually  com- 
plained of,  and  often  there  is  a  feeling  of  extreme  muscular  fatigue  and 
soreness.  The  psychic  depression  may  reach  a  stuporous  degree,  and 
this  may  follow  attacks  that  lack  muscular  violence.  There  is  a  decided 
tendency  to  mental  deterioration,  which,  in  the  majority  of  cases,  pre- 
senting frequently  repeated  major  or  minor  attacks,  markedly  tends  to 
dementia  in  the  end. 

Myoclonus  Epilepsy. — In  rare  instances  myoclonia  and  epilepsy 
occur  in  the  same  patient,  constituting  myoclonus  epilepsy  or  the  "  asso- 
ciation disease.' '  Such  cases  usually  show  marked  degeneracy,  and  the 
disease  begins  early  in  life.     Epilepsy  usually  antedates  the  myoclonic 

1  "  Annali  di  Xeurologia, "  1899.         ^  '^  rj^    ^h  p^t.  Xerv.  e  Ment.,"  iii,  1896. 
^  "Riv.  Sper  di  Freniat,"  1897. 


EPILEPSY.  611 

features  which  when  once  developed  usually  increase  in  severity  and 
commonly  eventuate  in  epileptic  convulsions. 

The  myoclonus  of  the  association  disease  is  somewhat  atypical  com- 
pared with  the  essential  myoclonias.  ^  The  contractions  are  usually 
lightning-like,  but  may  have  a  fibrillary  character,  involving  certain 
parts  of  muscles  only, — a  condition  described  as  "  live  flesh," — and 
such  manifestations  are  likely  to  develop  into  typical  myoclonic  con- 
tractions, though  they  may  remain  fibrillary  through  the  life  of  the 
patient,  A  single  general  tonic  contraction  may  rarely  constitute  the; 
entire  clinical  picture.  Myoclonus  contractions  end  imperceptibly  in 
the  tonic  stage  of  the  epileptic  paroxysm.  The  contractions  are  often 
strong  and  afPect  large  masses  of  muscles,  rendering  locomotion  difficult. 
The  trunk  is  frequently  affected,  causing  the  body  to  jerk  backward  and 
forward  and  laterally.  The  face  and  distal  portion  of  the  extremities 
are  frequently  involved.  Generally  the  myoclonus  is  symmetrical,  but 
both  sides  are  not  always  synchronously  involved.  Commonly  it  begins 
in  the  upper  extremities,  and  in  a  few  days  or  weeks  involves  the  lower 
extremities,  the  body,  neck,  and  face  in  the  order  given,  the  muscles 
about  the  eyes  and  mouth  being  the  last  affected.  The  tongue  and 
diaphragm  frequently  suffer,  in  severe  cases  producing  grunts  and 
barks,  a  sort  of  laryngeal  tic.  As  the  malady  develops  the  myoclonus 
becomes  more  and  more  persistent  during  the  waking  state,  having  a 
tendency  to  develop  the  myoclonic  status,  which  may  terminate  in  death. 
As  a  general  rule,  superficial  and  deep  reflexes  are  increased,  and  also, 
as  a  rule,  there  is  lack  of  physical  and  mental  development. 

The  prognosis  as  to  recovery  is  extremely  poor.  Those  who  have 
reached  advanced  years  present  extreme  senility  and  progressive, 
dementia. 

The  diagnosis  in  a  typical  case  is  easy.  There  are  family  types 
and  sporadic  cases,  the  majority  being  of  the  latter  variety.  The  con- 
dition may  be  acute  and  severe  or  mild  and  chronic. 

The  treatment  can  be  only  palliative,  but,  as  a  general  rule,  long 
remissions  both  in  the  myoclonus  and  the  epileptic  course  may  be 
obtained  by  the  use  of  bromids. 

The  General  State. — The  bodily  health  in  epileptics  may  leave 
little  room  for  complaint.  Very  commonly  they  present  gastric  dis- 
turbances, a  sluggish  skin,  and  constipated  bowels;  but  usually  this  is 
due  to  the  bromids  with  which  these  patients  are  so  commonly  satu- 
rated. Many  epileptics  have  gormandizing  habits  and  insatiate  appe- 
tites for  food.  This,  with  the  inactivity  often  forced  upon  them  by  the 
disease  and  reinforced  by  the  bromids,  leads  to  flabby  fatness.  As  a 
rule,  they  are  indifferent  and  careless,  and  often  the  finer  mental  attrib- 
utes and  the  keener  sensibilities  are  dulled  early  in  the  disease. 

Diagnosis, — The  diagnosis  of  epilepsy  is  often  very  difficult,  if  the 

attacks  are   incomplete  or    not  open  to  intelligent  observation.      The 

disease  in  the    nocturnal  form,  or  in   the  varieties  of  petit  mal  with 

slight  attacks,  may  not  attract  attention  for  years.     A¥hen  the  suspicion 

^  Clark  and  Prout,  "  Am.  Jour,  of  Insanity,"  Oct.,  1902. 


612 


NEUROSES. 


of  epilepsy  is  aroused, — as,  for  instance,  by  bed-wetting,  bloody  stains 
upon  the  pillow,  unexplained  bruises,  conjunctival  eccbymoses,  a 
dislocation  or  fracture  occurring  during  sleep,  cuts  on  the  face  or 
scalp,  a  bitten  tongue,  or  some  automatic  or  convulsive  attack, — a 
careful  investigation  will  rarely  fail  to  disclose  the  nature  of  the  disorder. 
In  such  cases  a  history  of  repeated  momentary  unconsciousness,  or  of 
some  of  the  various  sensory  aurae,  is  significant.  An  account  of  noc- 
turnal enuresis  or  nocturnal  pavor  in  childhood  is  suggestive.  Convul- 
sions during  teething,  the  marks  of  degeneracy,  or  the  presence  of  a 
family  neuropathic  trace  have  some  weight.  If  there  have  been 
repeated  convulsions,  and  they  conform  to  the  epileptic  type,  presenting 
sudden  onset,  with  or  without  warning,  tonic,  clonic,  and  stertorous 
stages,  and  complete  recovery,  there  is  little  room  for  doubt. 

We  have,  however,  to  exclude  the  epileptoid  fits  symptomatic 
of  various  functional  and  toxic  conditions.  Intestinal,  renal,  metallic, 
drug,  and  alcoholic  poisonings  may  cause  convulsions  that  very 
closely,  or  exactly,  copy  the  attacks  of  epilepsy,  and  they  may  induce 
epilepsy  in  those  predisposed.  Yertigos  of  gastric,  aural,  ocular,  and 
neurasthenic  origin  may  suggest  petit  mal.  Hysterical  convulsions  are 
often  mistaken  for  those  of  epilepsy.  Orgcinic  brain  disease,  such  as 
tumors,  cerebral  palsies  in  children,  and  brain  injuries,  may  occasion 
epileptiform  attacks.  Finally,  epileptic  seizures  may  be  of  the  apo- 
plectic form  and  suggest  cerebral  hemorrhage,  or  the  psychic  equiva- 
lents may  be  confused  with  transitory  mania.  In  every  case  it  is 
obligatory  to  examine  the  patient  rigorously  from  head  to  foot,  both  for 
the  purposes  of  diagnosis  and  treatment.  Of  epilepsy,  there  is  no  one 
pathognomonic  symptom.  The  following  table  shows  some  of  the 
diiferential  characters  of  epileptic  and  hysterical  convulsions  : 


Table  of  Differential  Characters  of  Epileptic  and  Hysterical  Attacks. 


The  Fit. 

Epilepsy. 

Hysteria. 

Prodromes. 

Mental  or  physical  premoni- 
tions. 

Emotional  disturbance. 

Aura. 

Common,  but  momentary. 

Common   and    of   considerable 

duration. 

Onset. 

Sudden,  complete  ;  cry.  fall, 
rigidity. 

Gradual. 

Consciousness. 

Instantly  lost. 

Partially  lost  or  retained. 

Course  of  convulsion. 

Tonic,  clonic,  and  stertorous 

stages. 

Epileptoid  and  emotional 
phases. 

Duration.                      Two  to  five  minutes. 

A  few  minutes  to  several  hours. 

Positions.                      Groverned  by  flexors,  mainly. 

Tendency  to  extension,  arc  de 
cercle,  opisthotonos,  crucifixa- 
tion  attitude,  etc. 

EPILEPSY. 


613 


Table  of  Differential  Characters  of  Epileptic  and  Hysterical  Attacks 

( Continued ). 


The  Fit. 

Epilepsy. 

Hysteria. 

Eyes. 

Pupils  dilated  and  rigid. 

Pupils  generally  mobile  and 
active. 

Tongue. 

Usually  bitten. 
Frothing  common. 

Bitten  very  exceptionally. 

Mouth. 

Frothing  absent. 

Sphincters. 

Relaxed,  usually. 

Usually  continent. 

Pulse. 

Accelerated  greatly  and  ten- 
sion increased. 

Rate  and  tension  not  much 
changed. 

Temperature. 

Elevated  1°  or  2°  F. 

Normal. 

Termination. 

In  hebetude;  gradual. 

Rather  prompt  ending  and  little 
discomfort. 

Urine. 

Increased    nitrogenous   and 
phosphatic  elements. 

Urea  reduced,  phosphates  de- 
creased, and  changed  phos- 
phatic formula  ;  often  large 
quantity,  but  of  low  specific 
gravity. 

Postparoxysmal  con- 
ditions. 

Petechial    ecchymoses,    re- 
duced muscular  strength, 
diminished        knee-jerks, 
mental   obscuration  ;    no 
memory  of  attack. 

No  motor  or  reflex  changes  ; 
some  recollection  of  phases  of 
attack ;  usual  mental  condi- 
tion at  once  regained  ;  pres- 
ence of  various  stigmata. 

Prognosis. — As  an  exception,  but  proving  the  rule  of  gravity  in 
the  prognosis  of  epilepsy,  rare  cases  recover  spontaneously.  In  a 
general  way  there  is  little  hope  for  cure,  if  the  disease,  with  repeated 
attacks,  has  lasted  over  two  years,  or  been  intense  in  its  manifestations 
for  even  a  shorter  period.  There  is  some  tendency  for  it  to  appear, 
subside,  reappear,  or  increase  at  the  developmental  epochs  of  dentition, 
puberty,  adolescence,  and  the  climacteric.  Any  inciting  cause  that  is 
controllable  is  a  favorable  consideration.  Epilepsy  as  a  manifestation 
of  degeneracy  is  of  bad  import.  If  there  is  any  reason  to  suppose 
that  organic  cortical  changes  have  occurred,  or  if  dementia  has  appeared^ 
the  outlook  is  unfavorable. 

A  single  attack  is  almost  never  fatal  of  itself,  but  a  condition  of 
status  is  very  likely  to  terminate  fatally,  and  every  attack  undoubtedly 
leaves  some  harmful  trace.  The  natural  termination  of  epilepsy  is  in 
dementia.  Death  by  status,  or  through  vascular  accident,  or  by  suffo- 
cation, or  other  physical  mishap  attending  a  fit,  is  not  so  very  rare. 
Epilepsy,  with  fits  at  long  intervals,  particularly  if  first  appearing  after 
twenty  years  of  age,  is  not  inconsistent  with  mental  qualities  of  a  high 
order,  and  may  not  shorten  life  or  abridge  usefulness.  The  majority  of 
epileptics,  under  proper  conditions,  may  be  advantageously  and  profit- 
ably employed  in  colonies  provided  for  the  purpose. 

Treatment. — A  systematic  study  of  the  patient  is  the  first  step 
toward   treatment.     Every  possible  source  of  local  irritation  must  be 


614  NEUBOSES. 

investigated.  Occasionally,  the  aura  may  direct  attention  to  some  body- 
disturbance  that  acts  as  an  inciting  cause  of  the  fits.  Asthenopia  due 
to  errors  of  refraction,  or  faulty  eye  muscles,  nasal  disease,  pharyngeal 
tumors,  maxillary  or  dental  faults,  gastric  inadequacy,  intestinal  para- 
sites, rectal  ulcers,  hemorrhoids  and  fissures,  constipation,  diarrhea, 
vesical  and  genital  troubles,  must  all  be  sought  and  corrected,  if  found. 
Toxic  conditions  are  equally  important.  Auto-intoxication  from  the 
stomach,  intestiues,  or  kidneys  must  be  stopped.  Alcohol,  lead,  tobacco, 
coffee,  tea,  and  dietetic  errors  may  incite  the  fits  in  those  predisposed. 
Hygienic  regulations  are  of  the  greatest  importance.  These  pertain  (1) 
to  the  diet,  which  should  be  nourishing,  easily  digested,  and  of  reason- 
able amount.  Milk,  fish,  vegetables,  and  suitable  fruit,  with  a  small 
amount  of  starchy  articles  and  a  very  little  meat,  is  generally  best  for 
epileptics.  In  some  instances  an  absolute  milk  diet  is  decidedlv  helpful, 
and  may  be  continued  for  many  months  with  advantage.  (2)  Baths  and 
exercise  to  keep  the  skin,  muscles,  and  circulation  active,  and  out-door 
life  to  further  the  same  end,  are  valuable.  Often  vigorous  manual  labor 
is  advisable.  (3)  The  rooms,  ventilation,  clothing,  occupation,  amuse- 
ments, and  habits  of  the  patient  are  worthy  of  full  consideration.  Do 
not  overlook  the  tendency  to  constipation. 

Improvement  under  such  measures  is  the  rule,  and  in  rare  instances 
it  is  one's  good  fortune  to  see  epilepsy  subside  after  the  removal 
of  some  irritation  or  the  correction  of  some  toxic  state. 

Turning  to  drugs,  the  most  importance  attaches  to  the  bromids,  but 
they  should  be  reserved  as  a  last  resort  or  as  an  adjuvant.  Cures  by 
the  bromid  treatment  are  not  to  be  expected.  It  is  at  best  a  palliative 
treatment  and  one  often  fraught  with  great  disadvantage.  Usually,  in 
order  to  completely  suppress  the  attacks  an  amount  of  bromid  is  re- 
quired that  maintains  constant  hebetude.  As  a  practical  fact,  if  the 
fits  are  not  controlled  by  sixty  grains  of  bromid  a  day,  the  question  is 
quite  stire  to  arise  whether  the  epilepsy  or  the  bromid  is  the  greater 
evil.  It  is  a  frequent  experience  to  see  patients,  brutalized  ])y  bromid, 
go  months  without  fits,  but  with  a  loss  of  mental  and  physical  activity. 
Sometimes  the  attacks  then  recur  with  seemingly  additional  violence,  or 
status  may  develop.  Among  the  bromids  there  is  little  choice,  but  the 
sodium  salt  is  least  likely  to  disturb  the  stomach.  During  the  use  of 
the  bromids  the  intestinal  tract  must  be  kept  aseptic  by  the  use  of  large 
quantities  of  drinking  water  or  some  of  the  laxative  waters,  and  the 
administration  of  some  antifermentative,  like  salol  or  betanaphtol. 
Omission  of  ordinary  table  salt  from  the  diet  it  is  claimed  aids  the 
action  of  the  bromid  by  facilitating  its  absorption.  ^  If  the  fits  are 
iiocttirnal,  the  medicine  should  be  given  after  the  evening  meal ;  if  tlfey 
•occur  on  rising,  the  largest  dose  shotild  be  administered  at  bedtime. 
AYheu  menstruation  aggravates  the  epilepsy,  the  doses  of  bromid  may 
ibe  doubled  for  a  few  days  before,  during,  and  after  the  period. 

Sometimes  the  use  of  antipyrin,  phenacetin,  trional,  or  other  of  the 
coal-tar  derivatives,  with  bromids,  gives  better  results  than  the  l^romids 
alone.  Digitalis  or  belladonna  in  similar  association  will  be  found 
^  Richet  aud  Toulouse,  Paris  Academy  of  Sciences,  Xov.,  1899. 


MIGRAINE.  615 

valuable  in  those  cases  where  there  is  weak  circulation.  Sumhul  and 
solanum  have  their  advocates,  but  so  has  had  every  other  remedy  ever 
known  to  man.  Flechsig  has  proposed  the  use  of  opium,  to  be  followed 
by  bromids,  in  cases  of  long  standing.  He  gives  o|)ium  in  doses  gradu- 
ally increasing  from  one  to  lifteen  grains  or  more  a  day,  if  well  borne, 
and  after  a  few  weeks  abruptly  stops  the  opium,  substituting  bromid, 
twenty  to  forty  grains,  three  times  daily.  Bechterew  combines  bromid, 
adonis  vernalis,  and  eodein  with  favorable  results.  Any  one  of  these 
plans  may  be  tried  when  bromid  alone  fails  or  loses  its  force.  Richet 
and  Toulouse  called  prominent  attention  to  the  asserted  value  of  with- 
drawing common  salt  from  the  food  of  epileptics,  thereby  securing,  it 
was  thought,  a  better  absorption  of  the  bromids.  A  very  general  trial 
of  this  measure  has  led  to  the  belief  that  it  is  one  of  decided  value,  and 
as  a  rule  smaller  doses  of  bromids  are  more  efficacious  under  this 
regime  than  larger  ones  without  it.  Even  alone,  without  the  use  of 
bromid,  the  withdrawal  of  salt  secured  a  reduction  of  the  number  of  fits 
in  fourteen  cases  reported  by  Garbini,  and  the  attacks  were  less  severe. 
The  plan  is  entitled  to  a  trial  in  all  cases,  but  is  often  very  difficult  to 
carry  out  in  the  usual  run  of  private  practice. 


CHAPTER  VIII. 
MIGRAINE. 

MiGRAiXE  is  an  explosive,  paroxysmal  psychoneurosis.  The 
attack,  usually  commencing  with  sensory  and  mental  symptoms,  is 
almost  always  attended  by  headache,  which  is  frequently  one-sided, 
and  there  is  generally  nausea  and  vomiting.  It  is  sometimes  called 
heynicrania,  sick  headache,  or  megrim.  Owing  to  the  vomiting,  it  is  often 
erroneously  attributed  to  biliousness. 

Etiology. — Heredity  is  often  strongly  marked.  It  is  more  com- 
monly direct  than  in  almost  any  other  neurosis.  Migraine  may  some- 
"times  be  traced  through  several  generations,  numbering  dozens  of  cases 
in  a  single  family  tree.  Any  neuropathic  family  is  almost  sure  to  pre- 
sent cases  of  migraine.  It  seems  capable  of  transmission  by  transfor- 
mation, alternating  with  hysteria,  epilepsy,  and  insanity.  It  may  be 
associated  with  the  graver  neuroses,  or  with  psychoses,  in  a  given 
patient.  Gout  and  arfhritism  have  similar  close  relations  with  it. 
Thirty  per  cent,  of  cases  begin  between  five  and  ten  years  of  age,  and 
the  balance  appear  mainly  at  puberty,  adolescence,  and  during  early 
adult  years.  In  rare  instances  it  may  begin  after  thirty.  The  female 
sex  is  somewhat  more  commonly  affected  than  the  male. 

The  inciting  cause  is  often  obscure.  Some  cases  date  from  periods 
of  lowered  j)hysical  hecdth  arising  from  any  cause.  The  cases  beginning 
in  early  childhood  very  frequently  follow  the  first  systematic  use  of  the 
eyes  for  near  vision,  as  in  school-work.  Eye-strain,  arising  from  accom- 
modative or  muscular  asthenopia,  is  certainly  competent  to  incite 
migrainous  attacks  in  those  predisposed.      Gouty  or  lithemic  conditions, 


616  NEUROSES. 

constipation,  indigestion,  fatigue,  lactation,  emotional  disturbance,  or  any 
febrile  movement  may  set  up  the  attack. 

Symptoms. — The  symptoms  of  migraine  are  those  of  the  attacks. 
These  vary  considerably  in  different  patients,  but  are  tolerably  uniform 
for  the  given  case.  There  are  usually:  (1)  Premonitory  symptoms; 
(2)  sensory  disturbances  ;  (3)  headache  ;  (4)  nausea ;  (5)  vomiting  ;  (6) 
sleep ;  and  (7)  complete  recoveiy,  occurring  generally  in  the  order 
given.  In  addition,  there  are  usually  vasomotor  symptoms  and  occa- 
sionally mental  and  motor  phenomena. 

The  premonitory  symptoms  are  most  common  in  the  cases  in  which 
the  early  sensory  symptoms  are  least  marked.  For  a  few  hours  or  a 
day  the  patient  feels  heavy,  dull,  apathetic,  and  is  usually  indifferent 
and  irritable.  There  may  be  slight  headache  or  somnolence.  After  a 
nap  he  may  wake  up  w^ith  a  fully  developed  one-sided  headache,  or  this 
may  be  present  on  awakening  in  the  morning.  The  sensory  symptoms 
occur  in  over  half  of  the  cases.  They  usually  begin  quite  suddenly. 
Bright  spots  before  the  eyes,  colored  rings,  luminous  zigzags,  hemi- 
anopsia, dimness  of  vision,  clouds,  etc.,  are  some  of  the  subjective  visual 
disturbances.  They  affect  both  eyes,  and  are  sometimes  lessened  if  the 
eyes  are  closed.  They  are  usually  most  pronounced  or  entirely  confined 
to  the  homologous  half  fields.  Some  patients  only  feel  a  vague  ocular 
discomfort,  or  decided  photophobia  may  be  present.  Taste  and  hearing 
are  exceptionally  affected  in  a  similar  manner.  In  some  cases  there  are 
sensory  symptoms  in  the  limbs,  face,  throat,  or  tongue,  but  especially  in 
the  hand  or  foot.  A  tingling  or  numl^ness  invades  the  parts  and  gradu- 
ally advances  toward  the  center.  These  sensory  disturbances  usually 
last  ten  to  twenty  minutes  and  then  subside,  the  headache  immediately 
displacing  them. 

Motor  symptoms,  though  exceptional,  are  very  valuable  indica- 
tions of  the  cerebral  nature  of  this  neurosis.  The  extremity  which 
presents  tingling  may  show  paresis,  and  the  following  headache  is 
usually  on  the  opposite  side.  Motor  aphasia  may  be  added  to  right-arm 
tingling  and  left  hemicrania,  and  the  left  halves  of  the  retina  may  be 
disturbed  by  visual  sensations,  which  are  referred  outM^ardly  to  the  right 
fields.  Temporary  word-deafness  has  also  been  recorded.  In  another 
group  of  rare  cases  there  is  transient  unilateral  paresis  of  the  oculo- 
motor, marked  by  ptosis,  outward  squint,  double  vision,  pupillaiy  dila- 
tation, and  loss  of  accommodation,  constituting  the  so-called  opjhthalmo- 
ptlegic  migraine. 

Slight  mental  changes  occur  in  some  patients,  such  as  depression, 
mental  confusion,  restlessness,  loss  of  memory,  stupor,  double  conscious- 
ness, or  a  recurrence  of  some  vivid  memory. 

The  headache  is  the  most  uniform,  dominant,  and  distressing  symp- 
tom. It  varies  in  different  cases  in  degree,  duration,  and  location,  but 
is  commonly  intense  and  ordinarily  circumscribed,  at  least  at  first. 
Often  commencing  as  a  localized,  intense  pain  in  a  small  spot  in  the 
temporal,  frontal,  ocular,  or  occipital  region,  it  gradually  spreads  to  the 
rest  of  the  same  side  of  the  head,  or  may  become  diffused  all  over  the 
head.     Less   commonly  it   commences   on   both   sides  as  a  frontal  or 


MIGRAINE.  617 

occipital  pain.  Rarely,  it  passes  down  the  back  of  the  neck  and  into 
the  arm.  The  character  of  the  headache  is  tolerably  uniform  in  the 
same  case,  but  some  patients  have  several  varieties,  which  reappear  from 
time  to  time,  and  are  recognized  as  old  acquaintances.  The  headache 
lasts  from  one  or  two  hours  to  ten,  twenty,  or  forty,  and  may  subside 
abruptly  after  nausea  or  nausea  and  vomiting,  or  gradually  grow  less  and 
disappear.  During  the  height  of  the  headache  the  patients  usually  shun 
light  and  noise,  and  remain  as  quietly  recumbent  as  possible.  Move- 
ment, such  as  rising  or  stooping,  intensifies  the  pain.  Tenderness  of 
the  scalp  or  nerve-trunks  is  unusual. 

In  most  cases  nausea  appears  after  the  headache  develops  or  has 
reached  its  height,  and  there  is  complete  anorexia.  Digestion  appears 
to  be  stopped,  as  unchanged  food  is  sometimes  vomited  many  hours  after 
its  ingestion. 

The  nausea  leads  to  vomiting  in  a  fair  proportion  of  the  cases,  and 
emesis  is  attended  by  much  retching  and  difficulty.  It  is  often  repeated 
and  protracted,  so  that  biliary  matter  may  finally  appear  in  the  ejecta. 
Usually,  once  commenced,  it  is  provoked  by  swallowing  any  fluid,  or 
even  by  the  saliva,  which  is  commonly  apparently  increased  in  amount. 
Often  the  patient  is  cold,  pinched,  clammy,  and  suggests  the  collapse  of 
seasickness  or  choleraic  disturbance.  Frequently,  as  the  vomiting 
subsides,  a  feeling  of  great  relief  is  experienced,  the  headache  ceases, 
and  the  patient  falls  into  a  quiet  sleep  of  a  few  minutes  or  several 
hours,  from  which  he  arises  and  asks  for,  or  tolerates,  a  little  food. 

The  vasomotor  symptoms  are  interesting,  and  have  attracted  great 
attention.  Early  in  the  attack,  before  the  headache  has  appeared,  there 
is  frequently  pallor  or  mottling  of  the  face.  In  some  instances  a  vivid 
red  streak  in  the  middle  of  the  brow  or  a  one-sided  flush  invariably 
appears.  The  pallor  is  succeeded  by  flushing,  in  some,  and  there  may 
be  general  profuse  perspiration.  Commonly,  the  extremities  are  cold 
during  the  severe  pain,  the  pulse  sharp  and  retarded.  Usually  the 
contracted  pupils  show  the  participation  of  the  cervical  sympathetic. 
This  rarely  is  unilateral,  and  may  produce  retraction  of  the  eyeball. 
The  inhibited  digestion  may  be  due  to  a  similar  angiospastic  condition 
of  the  gastric  arterioles.  As  the  attack  declines,  the  surface  reddens, 
the  pulse  resumes  its  proper  rate,  the  pupils  relax,  the  pallor  disappears, 
and  in  rare  cases  some  puffiness  in  the  scalp  has  been  noted.  Increased 
diuresis  may  follow.  In  the  intervals  the  patient  may  feel  perfectly 
well. 

Course. — Migraine  has  a  tendency  to  persist  for  many  years,  when 
once  established.  Commonly,  in  women,  after  the  menopause,  it  sub- 
sides, and  it  disappears  in  men  after  fifty-five  or  sixty.  The  attacks 
occur  with  more  or  less  regularity,  and  sometimes  with  remarkable 
periodicity.  Menstruation  may  provoke  it  monthly  in  women.  It 
sometimes  occurs  every  Sunday,  especially  in  men  who  change  their 
daily  routine  at  that  time.  Irregular  intervals  of  weeks  or  months 
may  intervene,  when  any  of  the  inciting  causes  may  precipitate  it ;  but 
it  is  usually  noticeable  that  an  inciting  cause  or  condition,  acting  soon 
after    an    attack,    fails    to    induce    an    immediate    recurrence.       It    is 


618  NEUROSES. 

evident  that  the  attack  has  cleared  the  atmosphere  and  exhausted  the 
susceptibility.  In  certain  rare  instances  the  migrainous  attacks  have 
been  replaced  by  epileptic  seizures  presenting  the  same  premonitory 
features.  A  case  has  been  seen  presenting  migraine,  epilepsy,  and 
transitory  mania,  apparently  as  alternating  equivalents.  Kralil-Ebing  ^ 
reports  a  number  of  cases  in  which  transitory  mental  disorder  occurred 
as  part  of,  or  in  alternation  with,  migraine.  The  premonitory  hemiopia 
in  a  case  reported  by  Xoyes  became  permanent.  In  advanced  years  the 
migraine  may  apparently  be  replaced  by  laljyrinthine  vertigo.  After 
many  attacks,  some  intellectual  impairment  has  been  noted.  Granting 
the  neuropathic  substratum  in  migraine,  the  association  or  succession  of 
other  neuroses  and  psychoses  is  surprising  only  by  its  rarity. 

Pathology. — In  the  absence  of  knowledge  regarding  the  morbid 
anatomy  of  migraine,  we  are  thrown  back  upon  theories  and  analogies. 
Attracted  by  the  vasomotor  symptoms,  many  attributed  the  migrainous 
attacks  to  disturbance  of  the  sympathetic.  This  is  a  clear  confusion  of 
effect  and  cause,  of  symptom  and  disease.  Taking  into  consideration 
the  cortical  features  manifest  in  sensory  disturbance,  hemiopia,  tingling, 
aphasia,  motor  loss,  crossed  heraicrania,  mental  features,  cardiac  and 
digestive  inhibition,  and  the  vasomotor  disturbance  itself,  there  can  be 
little  doubt  that  migraine  is  a  cerebral  disorder.  Its  resemblance  to 
epilepsy,  if  not  its  actual  relationship,^  points  to  the  same  conclusion. 
The  exact  nature  of  the  cortical  instability  is  for  the  future  to  reveal. 

Diagnosis. — The  diagnosis  of  migraine  depends  mainly  upon  its 
paroxysmal  and  recurrent  character  and  its  definite  clinical  features. 
The  sensory  premonitions  and  vasomotor  phenomena  are  very  significant 
when  present.  In  cases  presenting  migrainous  attacks  of  the  milder 
sorts,  it  is  difficult  to  be  sure  that  the  headache  is  not  due  to  some  ordi- 
nary cause,  until  its  repeated  recurrence  under  somewhat  similar  circum- 
stances declares  its  nature.  "  Sick  headache "  is  almost  invariably 
migraine.  The  vesperal  headaches  of  syphilis,  and  the  quotidian  or 
tertian  headaches  of  malaria,  occur  with  greater  periodical  regularity 
and  with  much  shorter  intervals  than  the  attacks  of  migraine.  Both  lack 
the  nausea,  vasomotor  symptoms,  and  complete  recovery.  From  j^^iii 
mal  the  diagnosis  may  often  offer  considerable  difficulty.  The  pre- 
monitory sensations  may  be  taken  for  an  aura,  but  their  prolonged  dura- 
tion is  unlike  the  momentary  warning  of  epilepsy.  Unconsciousness 
does  not  occur  in  migraine ;  it  is  the  most  constant  feature  of  epilepsy. 
Headache,  as  a  symptom  of  other  disease  developing  in  a  migrainous 
patient,  may  be  overlooked  and  the  concurrent  malady  neglected.  The 
headaches  of  Bright's  disease,  of  cerebral  tumor,  of  syphilis,  or  malaria 
may  be  wrongly  attributed  to  the  neurosis. 

Prognosis. — Migraine  is  usually  a  stubborn  and  persistent  malady. 
It  has  a  tendency  to  last  until  involutional  changes  in  the  organism 
commence,  when  it  frequently  spontaneously  subsides  by  a  gradual  in- 
crease of  the  intervals  between  the  attacks,  rather  than  by  a  lessening 
of  their  severity.      If  the  disease  is  of  short  duration,  and  some  remov- 

^  "Alienist  and  Neurologist,"  Jan.,  1900. 

2  Wilfred  Harris,  "  Transient  Hemiopias, "  "Brain,"  1897. 


NEUROSES  FOLLO  WING  TEA  UiUA  TISM.  619 

able  cause  can  be  discovered,  the  prognosis  is  fairly  good.  In  older 
cases  the  attacks  can  usually  be  rendered  less  frequent  and  often  aborted 
if  tlie  ])atient  is  watcliful  and  persists  in  treatment. 

Treatment. — Unless  the  condition  or  agent  provocative  of  the 
attacks  can  be  discovered  and  removed,  there  is  little  likeliiiood  of  fully 
successful  management.  To  this  end  all  sources  of  peripheral  irritation 
and  auto-intoxication  must  be  carefullv  investigated.  Eve-strain,  im- 
proper  diet,  excesses,  or  bad  habits  of  any  sort  must  be  corrected.  In 
some  migrainous  patients  any  relative  excess  of  nitrogenous  food  is  sure 
to  induce  an  attack.  As  a  rule,  for  these  patients  an  abundance  of  out- 
door air,  free  cutaneous  and  intestinal  excretion,  and  an  unstimulating 
diet  are  indicated.  A  tablet  of  y^  of  a  grain  of  nitroglycerin,  allowed 
to  dissolve  in  the  mouth,  and  taken  at  the  earliest  premonition,  will 
sometimes  abort  an  attack.  Catfein  has  a  similar  effect  witli  some 
patients.  Others,  by  taking  a  large  dose  of  bromid  and  lying  down, 
occasionally  escape.  Others,  again,  by  inducing  emesis,  or  by  washing 
out  the  stomach,  interrupt  the  paroxysm.  When  the  attack  is  once  on, 
heat  or  cold  to  the  head,  warmth  to  the  extremities,  and  a  mild  sinapism 
over  the  stamaeh  are  helpful.  A  dark,  quiet  room  is  usually  demanded. 
Morphin  will  control  the  pain,  but  should,  if  possible,  be  avoided,  to 
prevent  setting  up  the  opium-habit. 

If  the  attacks  are  of  considerable  frequency, — say  one  or  two  a  week, — 
a  continuous  course  of  bromid,  as  in  epilepsy,  may  give  good  results. 
In  the  forms  marked  by  paretic  symptoms  of  onset — by  ophthalmoplegia, 
for  instance — the  bromid  treatment  is  of  the  greatest  value,  and  such 
cases  should  be  managed  much  as  cases  of  epilepsy  with  incomplete 
attacks. 


CHAPTER  IX. 

NEUROSES  FOLLOWING  TRAUMATISM. 

The  subject  of  neuroses  following  injuries  is  one  of  vast  importance 
to  the  general  practitioner,  and  has  a  medicolegal  side  of  much  interest. 
The  question  has  been  greatly  befogged  for  many  reasons.  The  first 
important  work  directing  attention  to  this  class  of  cases  was  the  publi- 
cation of  Erichsen  in  1871  on  '^Spinal  Concussion,"  reprinted  in  1875. 
In  it  he  reports  fifty-three  cases  resulting  from  injuries,  received  mainly 
upon  railways.  These  cases  present  all  manner  of  lesions,  alone  hav- 
ing in  common  the  negative  feature — absence  of  external  evidence  of 
injury.  In  this  list  are  embraced  cases  of  fracture  of  the  dorsal  ver- 
tebrae, hemorrhage  into  the  cord,  division  of  the  cord,  meningitis,  simple 
nervousness,  hysteria,  neurasthenia,  and  pretty  much  everything  else. 
Unfortunately,  "  concussion  of  the  spine,"  as  set  forth  by  Erichsen, 
was  seized  upon  l)y  lawyers  as  the  basis  for  prosecuting  suits  for  damage 
against  corporations,  and  it  became  fixed  as  a  disease-entity  in  the  legal 
and  medical  mind.  In  1883  Page,  a  railway  surgeon,  brought  out  a 
book  written  from  an  ex  parte  standpoint  to  counteract  the  contentions  of 
Erichsen,  and  the  l^attle  raged  fiercely  from  both  sides  for  a  number  of 


620  NEUE08ES. 

years.  Subsequently,  in  Germany,  Oppenheira,  in  1889,  made  a  closer 
classification  between  organic  injuries  and  those  not  marked  by  gross 
histological  changes,  and  proposed  the  term  "  traumatic  neuroses  "  for 
the  latter.  About  the  same  time,  and  subsequently,  Charcot  taught  and 
demonstrated  that  the  nervous  symptoms  in  these  cases,  apart  from  those 
attributable  to  organic  lesions,  were  precisely  the  same  as  are  presented 
in  neurasthenia  and  hysteria. 

The  early  errors  of  Page  and  Erichsen  are  easily  understood  if  it  is 
recollected  that  the  finer  anatomy  of  the  nervous  system,  as  well  as  the 
physiology  of  the  cord,  was  but  little  known  in  their  time ;  that  the 
electrical  reactions  of  nerves  and  muscles  were  not  clearly  understood  ; 
that  the  stigmata  of  hysteria  and  the  symptom-group  of  neurasthenia 
were  still  undeciphered.  Unfortunately,  there  was  a  tendency  to  dignify 
all  the  morbid  conditions  following  serious  injury  by  such  terms  as 
"spinal  concussion,"  "railway  spine,"  "traumatic  neurosis,"  and 
"  Erichsen's  disease,"  without  any  attempt  to  distinguish  their  real 
significance  or  differentiate  among  them. 

It  must  be  evident  that  after  a  railway  injury,  as  after  injuries 
occurring  under  any  other  circumstances,  three  classes  of  conditions  may 
arise:  (1)  All  sorts  of  injuries  of  a  surgical  character;  (2)  traumatic 
hysteria ;  and  (3)  traumatic  neurasthenia.  Various  combinations  of 
these  three  may  result,  and  they  are  commonly  found  in  association. 
Surgical  conditions  and  neurasthenia  or  hysteroneurasthenia  may  be 
present,  or  neurasthenia  and  hysteria  may  alone  follow  concussions, 
injuries,  or  frights  attending  accidents,  especially  upon  the  railways.  It 
should  be  clearly  recognized  that  the  nervous  disturbances  marking 
neurasthenia  and  hysteria  are  likely  to  develop  in  proportion  to  the 
predisposing  tendency  in  the  individual,  and  also  in  proportion  to  the 
amount  of  mental  shock  attending  the  accident.  In  railway  accidents 
the  element  of  fright  reaches  its  highest  development,  and  consequently 
there  is  a  preponderance  of  neurasthenia  and  hysteria,  or  their  combi- 
nations, in  persons  the  victims  of  such  accidents. 

In  the  consideration  of  a  case  in  which  physical  conditions  and 
nervous  symptoms  have  originated  from  injury,  it  is  necessary  to  look  at 
it  first  as  a  surgical  case,  and  secondly  to  consider  it  as  a  nervous  case. 
Cranial  fracture,  cerebral  hemorrhage,  focal  epilepsy,  or  traumatic 
insanity  may  follow  injuries  to  the  head.  Dislocations  and  fractures  of 
the  spine,  lacerations  and  hemorrhages  of  the  cord,  myelitis  and  menin- 
gitis, muscular  strains,  and  ligamentous  ruptures  may  follow  blows  and 
injuries  to  the  back,  either  directly  or  indirectly  applied.  Concussion, 
if  sufficiently  severe,  even  without  apparent  local  physical  injury,  may 
induce  hemorrhages  in  the  meninges  or  in  the  cerebrospinal  apparatus. 
Accidents  producing  such  injuries  may  at  the  same  time  so  disturb  the 
nervous  equilibrium  that  neurasthenia  is  developed  or  hysteria  is  pro- 
voked. The  neurasthenia  of  traumatism,  or  of  fright  associated  with 
the  possibilities  of  traumatism,  is  exactly  the  same  as  neurasthenia 
arising  from  any  other  source.  Hysteria  associated  with  traumatism,  or 
conditions  associated  with  traumatism,  is  exactly  the  same  as  hysteria 
occurring    from    other    causes.      The    combinations    of    organic    with 


'  TICS.  621 

nervous  diseases  of  a  character  not  yet  associated  with  known  organic 
changes  must  be  deci])]iered  on  distinct  lines.  The  surgical  features 
have  their  own  prognosis  ;  the  nervous  disorders  have  their  proper  out- 
look, and  tliey  are  not  necessarily  related. 

Cases  of  this  character  may  be  considerably  complicated  by  litigation. 
In  exceptional  instances  there  is  dishonest  and  outright  simulation. 
More  frequently  the  anticipation  of  legal  proceedings,  the  numerous 
special  examinations,  the  suggestions  arising  from  attorneys  and  phy- 
sicians, and  the  very  natural  tendency  to  exaggeration  serve  to  highly 
accentuate  the  subjective  side  of  the  clinical  picture.  Corporations  and 
their  legal  and  medical  officers  usually  look  upon  all  such  claimants  as 
dishonest,  and  by  their  bearing,  if  not  by  their  words,  antagonize  and 
aggravate  the  patients  who  come  to  take  an  almost  morbid,  spiteful 
pleasure  in  cultivating  their  aches  and  bodily  and  mental  distress. 
They  see  damages  in  every  symptom,  and  the  hopeful  expectation  of 
physical  recovery  that  is  so  potent  for  good  is  completely  destroyed.  It 
not  infrequently  results  that,  upon  the  completion  of  litigation  and  the 
cessation  of  irritation  and  introspection,  prompt  improvement  takes 
place.  From  a  medical  standpoint,  it  is  always  better  that  an  immediate 
legal  settlement  be  made. 

The  profession  should  recognize  that  traumatic  neurasthenia  and 
traumatic  hysteria  are  serious  and  disabling  conditions.  Every  case 
must  be  specialized  and  the  amount  of  disability  and  the  probability  of 
its  duration  must  be  estimated  from  all  the  facts. 


CHAPTER  X. 
TICS, 


Tic,  Maladie  des  tics,  Mimic  Spasm,  Habit  Spasm. — Recent 
French  ^vriters,  following  Tourette,  make  a  sharp  distinction  between  <i 
tic  and  other  varieties  of  spasm.  After  them  a  tic  is  a  spasm  which  is 
identical  with  movements  of  volitional  intent  and  contains,  therefore,  a 
psychic  element  which  may  be  subconscious.  It  is  a  psychoneurosis. 
In  facial  tic  they  call  attention  to  the  winking  of  the  eye,  exactly  like  that 
which  excludes  a  flying  particle  of  dirt ;  to  the  movements  about  the 
mouth  and  nose,  identical  with  those  produced  by  sensations  of  taste 
or  smell,  and  to  the  occasional  functional  association  with  these  of 
swallowing  efforts,  laryngeal  motions,  the  production  of  sucking  or 
smacking  sounds,  of  grunting,  and  of  articulate  words,  sometimes  of  an 
indecent  character  (coprolalia).  A  facial  appearance  that  is  expressive 
of  some  emotion,  as  of  grief,  pain,  fright,  or  joy,  may  be  repeated  by 
the  tic.  Some  cases,  becoming  more  wide-spread,  involve  the  neck  and 
upper  extremity  so  that  attitudes  and  gestures  are  produced  in  con- 
formity with  the  underlying  mental  idea.     These  tics,  of  which  blepharo- 


622 


NEUIiOSi:S. 


spasm  is  a  type  and  coprolalia  the  extreme  development,  are  more  or 
less  under  the  control  of  the  patient,  who  can,  by  an  eifort  of  will,  do 
considerable  to  repress  them.  After  such  repression  "  tiquers "  are 
likely  to  feel  more  or  less  vague  discomfort  and  often  yield  to  a  regular 
spasmodic  debauch,  which  seems  to  give  them  a  feeling  of  relief. 
During  sleep  this  spasm  completely  subsides.  Such  patients  frequently 
present  a  most  marked  neurotic  heredity,  and  sometimes  other  neuroses, 
as  writers'  cramp  and  hysteria,  or  mental  and  moral  obliquities  are 
present. 

Ordinarily,  a  tic  is  rapidly  executed,  and  may  be  repeated  with  great 
rapidity  from  two  to  scores  of  times,  when  a  lull  occurs  for  a  few  min- 
utes, or  perhaps  an  hour  of  quietude  may  intervene.  Any  excitement 
or  embarrassment  promptly  recalls  and  intensifies  the  morbid  motions. 


Fig.  266.— Facial  tic. 


Fig.  267.— Mental  torticollis. 


On  the  other  hand,  any  decided  interest  fixing  the  patient's  attention 
interrupts  the  twitchings.  The  spasm  has  a  tendency  to  invade  neigh- 
boring muscles  of  associated  function,  and  frequently  becomes  bilateral, 
but  is  seldom  symmetrical,  excepting  those  tics  more  or  less  limited  to 
the  face,  especially  to  the  nose  and  mouth.  While,  ordinarily,  the 
spasms  are  purely  clonic,  they  may,  in  a  part  or  the  whole  of  their  dis- 
tribution in  long-standing  cases,  present  tonic  features  of  greater  or  less 
duration.  In  some  instances  the  eyelids  are  so  firmly  closed  that  the 
pressure  upon  the  eyeball  is  painful.  Rigidity  in  the  lips  is  complained 
of  at  times  as  a  feeling  of  stiffness,  and  the  action  of  the  zygomatics 
and  buccinator  may  keep  the  angle  of  the  mouth  persistently  retracted 
and  elevated.  The  neck  may  be  rigidly  held  in  a  given  position.  A 
somewhat  similar  spasm  is  often  noted  after  Bell's  palsy.  It  is,  how- 
ever, always  unilateral,  the  affected  muscles  are  distinctly  contractured 
(see  page  119),  and  it  does  not  so  distinctly  imply  purpose. 

Etiolog-y. — Youth  is  the  preferred  age  for  the  development  of  tics, 
but  adult  life  is  not  spared.  An  appreciation  of  the  mental  substratum 
of  tics  enables  one  to  comprehend  something  of  their  genesis  and  in- 


'  TICS.  623 

tractability.  There  is  no  doubt  that  many  cases  of  blepharospasm 
originate  in  some  irritation  of  the  ocular  apparatus  that  forces  the  atten- 
tion of  the  patient  into  a  groove  leading  to  a  mental  and  motor  habit. 
These  tics  have  for  long  been  well  called  haljit  spasms.  The  term 
habit  chorea,  also  applied  to  them,  is  misleading,  though  they  may  be 
grafted  upon  a  chorea  as  a  sequel  by  suggestion.  In  the  same  way  a 
protracted  grief,  chagrin,  or  ecstatic  pleasure  may,  in  one  neurotically 
predisposed,  furnish  the  subconscious  factor  for  an  expressiojial  tic,  which 
reproduces  exactly  the  facies  of  the  underlying  idea,  perhaps  made 
grotesque  by  its  unilateral  distribution.  The  thread  can  sometimes  be 
followed  by  covering  the  sound  side  of  the  face  and  trying  to  interpret 
the  emotion  expressed  by  the  tic.  Sniffing,  swallowing,  and  phouation 
are  merely  the  manifestations  of  functional  association,  and  coprolalia  is 
but  the  v^ocalization  of  the  imperative  concept  that  may  be  otherwise 
subconscious.  A  facial  spasm  is  sometimes  associated  with  neuralgia  of 
the  fifth  nerve,  and  bears  the  distinctive  and  classical  name  of  tic  dou- 
loureax;  the  spasm,  however,  is  secondary  to  the  pain  and  expressive  of 
it.  It  is  a  grimace,  but  may  persist  after  pain  ceases  as  a  true  tic.  A 
tic  in  the  limited  sense  is  not  painful. 

Varieties. — Aside  from  the  habit  movements  of  idiocy  and  dementia, 
which  constitute  reversionary  or  degenerate  tics,  we  may  enumerate 
blepharospasm,  facial  spasm,  spasmodic  torticollis,  mental  torticollis,  the 
latah  of  India,  the  myriachit  of  Siberia,  the  jumpers  of  New  England 
and  Canada.  1 

In  mental  torticollis  ^  some  deviation  of  the  head  is  customary  and 
is  spasmodically  maintained.  Ordinarily,  it  ceases  when  the  patient 
lies  down  or  it  can  be  controlled  by  a  slight  amount  of  manual  pressure 
upon  the  head  or  face. 

Jumpers  and  the  subjects  of  latah  and  myriachit  execute  any  one  of 
several  commands  or  suggestions  impulsively,  often  violently,  and  fre- 
quently against  their  apparent  Avill.  Thus,  upon  command,  they  may 
strike,  jump,  or  unclothe  themselves. 

Treatment. — In  all  cases  of  facial  tic,  after  general  measures,  we 
are  to  look  for  and  correct  any  peripheral  irritation  that  can  be  asso- 
ciated with  the  seventh  nerve.  This  is  particularly  the  case  in  the  dis- 
tribution of  the  sensory  portion  of  the  fifth,  but  irritation  arising  even 
at  a  distance,  as  in  the  intestines  or  pelvis,  may  maintain  the  tic,  and 
when  corrected  the  tic  may  subside.  Pressure  upon  certain  points  in 
the  distribution  of  the  fifth,  first  described  by  Graefe,  often  checks  the 
tic.  The  most  usual  one  is  at  the  supraorbital  notch.  In  a  general 
way  they  correspond  to  the  tender  points  of  Valleix  and  the  maxima 
of  Head.  We  should  always  and  repeatedly  search  for  them  carefully, 
going  over  the  neck,  shoulders,  and  upper  chest,  as  they  are  sometimes 
distantly  located.  By  exerting  pressure  upon  such  a  part,  the  tic  seems 
to  be  reflexly  inhibited,  and  the  habit  is  arrested,  at  least  temporarily. 
By  repeating  the  arrest  frequently  and  for  long  periods,  the  habit  may 

1  Jos.  Collins,  "Med.  News."  Dee.  11,  1897. 

2  Bompairs,  "These  de  Paris,"  1894,  and  Brissaud,  "Lemons,"  1895. 


624  NEUROSES. 

be  fully  broken.  In  the  same  way  the  use  of  faradic  electricity  will 
occasionally  render  service.  For  this  purpose  the  muscles  engaged  in 
the  tic  should  be  thrown  into  powerful  tonic  contractions  for  a  number 
of  minutes,  from  five  to  fifteen.  One  pole  taken  in  the  hand  and  the 
other  placed  over  the  stylomastoid  foramen,  or  on  the  particular  facial 
branch  indicated,  makes  a  suitable  arrangement.  The  patient  may 
advisably  keep  a  battery  at  hand  and  use  it  as  often  as  the  tic  becomes 
marked.  It  for  the  time  being  teaches  the  muscle  a  steady  contraction 
and  perhaps  favorably  affects  the  mental  state  by  the  peripherally 
induced  suggestion.  At  any  rate  such  application  is  often  followed  by 
temporary  marked  relief,  and,  in  fortunate  cases,  by  practical  cure.  A 
sugar  pill,  to  be  taken  with  great  exactness  every  thirty  minutes,  has 
served  a  good  purpose  by  constantly  reminding  the  patient  of  the  phy- 
sician's suggestions,  and  recalling  his  attention  to  voluntary  self-control. 

Finally,  nerve-stretching  may  be  employed.  If  thoroughly  done,  it 
induces  paralysis  for  a  longer  or  shorter  time,  but,  unfortunately,  a 
restoration  of  motor  function  usually  is  marked  by  the  reappearance  of 
the  tic,  for  which  the  irritation  in  the  healing  nerve-trunk  may  be 
responsible.  A  tendency  to  relapse  in  these  cases  is  marked.  The 
deeper  the  mental  tare  and  the  more  pronounced  the  neurotic  back- 
ground, the  less  are  they  manageable.  It  is  not  impossible  that  sugges- 
tion, by  reaching  the  subconscious  element,  may  sometimes  yield  favor- 
able results.  All  varieties  of  retention  dressings  and  appliances  are  at 
first  apparently  helpful,  but  shortly  become  irksome,  unbearable,  and 
harmful. 

In  mental  toriicollis,  Feindal  ^  has  reported  good  results  by  massage 
and  exercises,  the  purpose  of  which  was  to  build  up  the  patient's  self- 
control  and  mental  stamina.  With  these  he  associated  encouragement 
(suggestion)  and  general  tonic  measures.  The  exercise  treatment  em- 
braces two  varieties  of  motor  effort.  First,  the  patient  practises  volun- 
tarily controlling  the  spasmodic  muscles  by  keeping  them  at  rest. 
Second,  the  affected  muscles  are  alternately  contracted  and  relaxed 
methodically  a  dozen  times.  These  exercises  should  be  repeated  hourly. 
It  is  only  by  attacking  the  mental  element,  the  obsession,  that  the  psy- 
choneurosis  can  be  managed  and  the  various  suggested  measures  are  a 
means  to  that  end. 

1  "  Nouv.  Icon,  de  la  Salpet.,"  Dec,  1897. 


PART  VIII. 
SYMPTOMATIC  DISORDERS. 


There  are  a  number  of  symptomatic  disorders  very  commonly  met 
with  in  nervous  maladies  and  essentially  nervous  in  character  that 
nearly  reach  the  dignity  of  diseases.  Headache,  vertigo,  insomnia,  and 
neuralgia  are  the  most  important.  Headache  and  vertigo  have  been 
specifically  emphasized  whenever  they  had  a  special  relation  to  diseases 
of  the  nervous  apparatus,  and  can  be  easily  followed  from  the  index. 
Neuralgia  and  sleep  disorders  require  further  study. 


CHAPTER  I. 

NEURALGIA. 

Neuralgia  (nerve  pain)  is  always  a  symptom.  Difficulty  arises 
from  the  fact  that  intense  neuralgic  affections  have  often  been  confused 
with  their  most  prominent  painful  symptoms.  Neuritis  and  neuralgia 
have  been  differentiated  only  in  recent  years.  Even  now  there  are  many 
who  fail  to  discriminate  between  trifacial,  brachial,  and  sciatic  neuri- 
tides,  and  neuralgias  of  similar  location.  It  also  appears  proven  that 
an  irritation  at  first  producing  neuralgia  may,  by  its  persistence,  set  up  a 
neuritis,  and  it  is  certainly  clear  that  neuralgia  is  one  of  the  symptoms 
of  neuritis.  The  distinction,  therefore,  is  not  always  easy.  Neuralgia 
may  be  an  expression  of  disturbance  acting  (1)  locally,  or  (2)  systemi- 
caliy,  or  (3)  in  both  ways  at  once.  Neuralgias  may  be  visceral  or  periph- 
eral, and  many  visceral  diseases  have  their  corresponding  peripheral 
or  somatic  neuralgias.  In  this  relation  the  reader  is  referred  to  the 
section  on  Pain  and  the  Referred  Pains  of  Visceral  Disorders  as  outlined 
by  Head  (p.  56,  et  seq).  Many  neuralgias — such  as  angina  pectoris  in 
cardiac  disease,  intercostal  neuralgia  in  gastrohepatic  disease,  testicular 
neuralgia  in  kidney  disease,  pleurodynia,  gastrodynia,  and  coccygodynia 
— are  very  clearly  symptomatic  and  secondary.  There  are  certain  condi- 
40  625 


626  SYMFTOJIATIC  DISOBDEES 

tioDS  favoring  the  appearance  of  neuralgia,  and  there  are  a  few  localized 
neuralgias  that  require  individual  consideration. 

Conditions  Favoring  Neuralgias. — Intense  neuralgic  conditions 
are  rare  in  early  life  and  in  old  age,  but  when  they  appear  after  sixty, 
thev  usually  have  an  irremediable  organic  basis  and  are  correspondingly 
intractable.  Women  suifer  in  this  way  more  than  men.  In  some 
instances  there  is  a  marked  hereditary  tendency,  and,  as  a  rule,  the 
"  nervous "  and  neurotic,  the  possessors  of  unstable  nerve-cells,  are 
most  prone  to  neuralgic  conditions.  This  shows  out  strongly  in  the 
clinical  histories  of  hysteria  and  neurasthenia.  Arthritism  in  its  broad- 
est sense  is  a  congener. 

The  inciting  causes  of  disturbance  marked  by  neuralgic  features  are 
very  numerous.  Any  impairment  of  health,  any  debilitating  influence, 
any  continuous  fatigue,  anemia,  emotion,  concussion,  may  be  symptom- 
atized  by  neuralgia.  Exposure  to  cold,  peripheral  local  irritations,  and 
any  cause  of  neuritis,  as  well  as  every  form  of  neuritis,  may  set  up 
neuralgic  pains.  Nearly  all  toxic  influences  may  induce  neuralgia. 
Those  toxic  causes  which  are  so  active  in  the  etiology  of  neuritis  may 
induce  neuralgic  pain.  Lead,  alcohol,  diabetes,  auto-intoxication,  mala- 
ria, and  acute  infections  may  all  have  neuralgic  symptoms.  The  root 
pain  of  tabes,  the  peripheral  pains  of  cortical  brain  disease,  and  the 
nerve  pains  of  neuromata  are  easily  understood. 

Characters  of  Neuralgic  Pains. — Neuralgic  pains  are  commonly 
unilateral,  and  confined  to  the  distribution  of  a  part  or  the  whole  of  a 
single  nerve,  or  of  several  nerves.  The  pain  is  inconstant  and  usu- 
ally paroxysmal,  with  complete  freedom  in  the  intervals,  or  with  a  dull 
ache  between  the  severe  pains.  They  are  usually  described  as  dart- 
ing, stabbing,  tearing,  ripping,  lightning-like,  as  if  shot,  and  by  other 
words  or  phrases  expressing  their  sudden,  instantaneous  character. 
They  may  be  repeated  rapidly  during  a  few  minutes,  or  occur  singly 
at  longer  intervals.  The  pain  is  located  deeply  in  the  parts,  but  often 
is  attended  by  great  superficial  hypersensitiveness.  At  the  same  time 
deep  pressure  may  give  relief.  During  the  painful  attacks,  motion  of 
the  muscles  of  the  parts,  a  touch,  even  a  breath  of  air  in  severe  cases, 
mav  renew  the  stabbing  pains.  Heat,  cold,  and  alcoholics  may  intensify 
or  diminish  the  pain  in  various  cases. 

Neuralgic  areas  during  the  pains  and  between  the  paroxysms 
usually  present  nerve  tenderness.  This  is  most  prominent  at  certain 
points  where  the  nerve  is  superficial,  overlies  bone,  or  is  inclosed  l^y 
fascia  or  other  rigid  tissue.  They  correspond  to  the  "  maxima "  of 
Head  and  constitute  the  "  tender  points  "  of  Valleix. 

In  some  cases  the  pain  has  a  tendency  to  radiate  into  other  brandies 
of  the  same  nerve  or  into  related  nerves.  In  the  same  way  irritation  of 
one  branch  of  a  nerve,  especially  of  the  trifacial,  may  induce  neuralgia 
in  another  division.  Neuralgic  pains  are  often  ver}^  fugaceous,  appear- 
ing now  here,  now  there,  especially  when  arising  from  systemic  causes. 

The  associated  muscles  may  act  spasmodically  in  the  pain  storms. 
This  is  rather  common  in  the  trifacial  form,  but  it  is  difficult  to  tell 
whether  the  grimace  is  volitional  or  not.     In  the  same  way  a  sharp 


NECRALGIA.  627 

leg  neuralgia  may  be  attended  by  a  drawing  up  of"  the  limb,  and,  if"  the 
patient  is  walking,  he  may  suddenly  fall. 

Very  often  the  parts  subject  to  neuralgia  show  vasomotor  disturb- 
ance and  trophic  changes.  The  vessels,  at  first  constricted,  usually 
dilate,  and  flushing  follows.  Edema,  local  sweating,  erj'thema,  scali- 
ness,  loss  of  hair,  blanching  of  the  hair,  herpes,  and  pigmentation  may 
attend  upon  neuralgia  that  is  symptomatic  of  a  neuritis.  Localized 
hypertrophy,  due  to  the  continued  congestive  features  of  neuralgia,  may 
be  encountered. 

Pathology. — The  mechanism  of  neuralgic  pains  has  been  a  fruitful 
theme  of  discussions,  into  which  we  need  not  enter.  The  following 
facts  indicate  the  interposition  of  the  spinal  apparatus  in  neuralgic 
pains  :  (1)  The  pain  may  occupy  the  areas  related  to  several  spinal 
segments,  and  not  closely  follow  the  distribution  of  nerves.  In  shingles, 
for  instance,  the  herpetic  and  painful  area  on  the  upper  trunk  is  bounded 
by  horizontal  planes,  and  not  by  the  intercostal  furrows ;  (2)  irritation 
of  one  branch  of  the  nerve  may  be  radiated  into  another,  which  it  could 
only  reach  by  way  of  the  nuclear  cells  ;  (3)  the  pain  may  develop  exclu- 
sively in  another  region  than  the  one  irritated  ;  (4)  division  of  the  poste- 
rior nerve-root,  as  has  been  done,  especially  by  Abbe  and  others,  or 
separation  of  the  afferent  path  anywhere  between  the  cord  and  lesion, 
immediately  stops  the  neuralgia ;  (5)  irritation  of  the  proximal  stumps 
of  a  divided  nerv^e  gives  rise  to  pain  referred  to  the  peripherv-  to  which 
that  nerve  is  anatomically  related.  This  is  seen  in  amputation  neuro- 
mata and  in  anesthesia  dolorosa. 

By  this  conception  we  are  able  to  understand  how  systemic  poison- 
ing, as  by  alcohol  or  malaria,  may  so  predispose  the  spinal  ganglia  that 
pain  is  occasioned  by  a  peripheral  disturbance,  perhaps  insignificant  in 
itself.  It  also  explains  the  ability  of  an  intense  or  protracted  peripheral 
irritation  to  set  up  localized  pain,  which  may  long  persist  after  the  irri- 
tant condition  has  subsided. 

Varieties  of  Neuralgic  Pains. — An  enumeration  of  the  common 
varieties  of  neuralgic  pains  is  all  that  need  be  attempted.  Thev  are 
classified  (1)  as  to  location,  and  (2)  as  to  cause. 

Varieties  Depending  upon  Location. — Trifacial,  cervico-occipital,  cer- 
vicobrachial,  brachial,  dorso-intercostal,  intercostal,  lumbo-abdominal, 
spinal,  sacral,  coccygeal,  sciatic,  crural,  metatarsalgia,  etc.  A'isceral 
forms  :  Pleurodynia,  angina  pectoris,  cardialgia,  gastralgia,  gastrodynia, 
hepatalgia,  enteralgia,  nephralgia,  ovaralgia,  testicular  neuralgia,  etc. 

Varieties  Depjending  on  Cause  or  Association. — Epileptiform  neu- 
ralgia, really  a  neuralgic  facial  tic  ;  reflex  sympathetic  neuralgia,  one  in 
which  the  pain  appears  at  a  distance  from  its  irritant  source  ;  traumatic 
neuralgias,  really  traumatic  neuritis  ;  occupation  neuralgias,  a  part  of 
occupation  or  fatigue  neuroses ;  herpetic  neuralgias,  the  neuralgic  pains 
attending  zoster ;  hysterical  neuralgias,  really  stigmata  of  the  neurosis  ; 
rheumatic,  gouty,  diabetic,  anemic,  and  malarial  neuralgias,  associated 
with,  and  often  due  to,  the  respective  systemic  states  ;  syphilitic  neu- 
ralgia, very  rare,  and  due  to  the  syphilitic  cachexia.  Pains  in  syphilis 
are  ordinarily  due  to  neoplastic  infiltration  of  the  nerves  and  other  tis- 


628  SY3IPT0MATIC  DISORDERS. 

sues ;  degeneration  neuralgia  appears  in  the  aged,  and  is  due  to  involu- 
tional changes  in  the  organism. 

Trifacial  Neuralgia. — Of  all  varieties  of  neuralgia,  that  occurring 
in  the  trifacial  is  the  most  important.  It  often  is  extremely  persistent 
and  intractable.  The  constant  exposure  of  the  fifth  pair  in  the  face  and 
nasopharynx  to  injury  and  infection  of  the  periphery,  the  course  trav- 
ersed by  the  nerve  through  bony  channels  and  over  resisting  struc- 
tures, and  its  very  extensive  distribution  territory,  lay  it  especially  liable 
to  irritating  and  traumatic  conditions.  Its  association  with  other  cranial 
nerves  sometimes  causes  it  to  be  reflexly  affected,  as  from  the  motor 
oculi  and  pneumogastric.  It  is  affected  about  equally  often  on  either 
side,  and  very  rarely  bilaterally.  Exceptionally,  all  three  branches  are 
painful,  but  more  commonly  the  neuralgia  is  confined  to  one  or  two  of 
theui. 

When  the  first  branch  is  affected,  the  pain  is  supraorbital,  radiating 
from  the  supraorbital  foramen  over  the  corresponding  side  of  the  brow, 
or  even  to  the  vertex.  The  eyeball  is  frequently  tender,  or  may  be  the 
seat  of  neuralgic  pains.  Tender  points  are  usually  found  at  the  notch, 
on  the  upper  lid,  and  over  the  lower  margin  of  the  nasal  bone.  When 
the  second  division  is  affected,  the  pain  is  located  over  the  cheek,  between 
the  orbit  and  the  mouth,  spreading  onto  the  wing  of  the  nose.  The 
tender  points  are  at  the  lower  border  of  the  nasal  bone,  over  the  malar 
prominence,  at  the  infraorbital  foramen,  on  the  gum  above  the  canine 
tooth,  and  sometimes  on  the  hard  palate.  In  neuralgia  of  the  third 
division,  pain  traverses  the  lower  jaw  and  tongue  and  the  corresponding 
portion  of  the  face,  extending,  by  the  auricular  branches,  to  the  zygo- 
matic, and  even  to  the  parietal  region.  The  tender  points  are  over  the 
inferior  dental  foramen,  in  the  temple,  and  in  the  parietal  regions. 

The  pain  is  usually  intense,  lancinating,  shock-like,  and  may  cause 
the  most  excruciating  torture.  The  attacks,  if  at  all  severe,  usually 
cause  vasomotor  and  secretory  disturbance.  Lacrimation,  salivation, 
and  mucous  discharge  from  the  nose  may  be  encountered.  The  brow,  or 
lip,  or  tongue,  or  the  entire  side  of  the  face,  may  be  swollen  and  edem- 
atous. The  hyperalgesia  is  often  intense,  so  that  wiping  the  nose  or 
eye,  taking  liquids  into  the  month,  and  mastication  are  attended  by 
great  suffering,  and  often  provoke  a  repetition  of  the  neuralgic  pains. 
Herpes  possibly  only  occurs  when  histological  changes  in  the  nerve  or 
its  nucleus  have  taken  place. 

The  neuralgias  of  the  brachial,  intercostal,  and  sciatic  nerves  are 
often  intense,  and  present  similar  tender  points  and  superficial  hyper- 
algesia.    The  location  of  both  have  been  described  on  page  56,  et  seq. 

Treatment. — The  treatment  of  a  symptom  is  necessarily  the  treat- 
ment of  the  underlying  disease.  Local  and  constitutional  conditions 
capable  of  determining  neuralgic  pains  must  be  carefully  sought,  and 
local  conditions  capable  of  producing  neuralgia  at  a  distance  must  not 
be  overlooked.  In  order  to  specialize  the  matter  we  may  consider  the 
treatment  of  trifacial  neuralgia  in  detail.  With  proper  variations  the 
same  considerations  and  measures  apply  to  other  neuralgias. 

Treatment  of  Trifacial  Neuralgia. — In  the  treatment  of  a  tri- 


NEURALGIA.  629 

facial  neuralgia  a  careful  search  for  local  irritation  i.s  first  to  be  made. 
In  many  cases  pressure  upon  a  given  point  will  check  or  inhibit  the 
pain.  If  such  an  inhibiting-  point  can  be  found,  it  is  a  source  of  great 
relief  to  the  patient.  If  the  pain  is  intense  and  the  hyperalgesia  severe, 
the  use  of  morphin  or  cocain  may  be  required  to  make  the  examination. 
This  should  commence  at  the  vertex.  The  scalp  and  brow  should  be 
carefully  palpated,  the  orbit  investigated,  the  eye  examined  for  refractive 
errors,  local  inflammation,  and  glaucoma.  The  nasal  fosspe,  the  antra, 
the  nasopharynx,  the  mouth,  and  especially  the  jaws,  must  l)e  thoroughly 
scrutinized.  It  is  useless  to  sacrifice  teeth  unless  a  competent  dentist 
finds  them  diseased.  As  a  rule,  a  careful  dental  overhauling  is  a  nec- 
essary measure  in  protracted  cases,  even  where  the  pain  is  not  located 
in  the  dental  branches. 

The  general  systemic  state  is  of  equal  importance.  The  facial  neu- 
ralgias of  infections,  grip,  malaria,  and  eye-strain  commonly  involve 
the  ophthalmic  division.  Dental  and  maxillary  disease  is  most  common 
in  the  middle  branch.  Compression  of  the  nerve  in  the  dental  canal 
often  causes  neuralgia  of  the  third  branch.  In  elderly  people  who  have 
lost  their  teeth  the  resulting  greater  elevation  of  the  chin  stretches  the 
dental  branch  of  the  third,  and  may  cause  a  neuralgia  that  can  be 
readily  relieved  by  the  use  of  dental  plates  of  proper  vertical  propor- 
tions to  prevent  the  tug  upon  the  affected  nerve.  Anemias,  cachectic 
states,  and  conditions  of  auto-intoxication  from  the  kidneys,  stomach, 
or  intestines,  must  be  corrected.  Neoplasms  in  the  cranial  cavity,  or 
facial  fossae,  jaws,  and  antra,  may  impinge  upon  the  nerve  and  set  up 
neuralgic  pains. 

In  the  management  of  these  cases  it  is  usually  necessary  to  maintain 
complete  rest.  Many  cases,  otherwise  rebellious,  improve  very  rapidly 
under  the  Mitchell  rest  system.  Food  must  usually  be  taken  in  a  liquid 
form,  and  in  very  severe  cases  the  nasal  tube  must  be  employed.  Masti- 
cation ordinarily  provokes  the  pains.  Directed  against  the  pain  we  have 
in  malarial  cases  to  employ  large  doses  of  quinin,  or  Warburg's  tinc- 
ture, or  both,  for  several  days,  and  follow  them  with  arsenic,  iron,  and 
quinin  in  moderate  doses  for  weeks.  The  purpose  is  to  cinchonize  the 
patient  and  maintain  a  saturation  of  the  blood  w'ith  quinin.  A  prepara- 
tory calomel  purge  is  of  importance.  In  other  cases  w^e  have  to  resort 
to  sedatives,  and  are  usually  reduced  finally  to  the  use  of  morphin.  The 
reliable  aconitia  of  Duquesnel,  in  doses  of -3-^  of  a  grain,  several  times 
a  day,  is  sometimes  of  great  service,  and  may  be  increased  if  well  borne. 
Slight  numbness  of  the  lips,  tongue,  and  fingers  may  be  expected,  and 
this  amount  of  action  can  not  safely  be  exceeded.  Cocain,  by  local 
hypodermatic  administration  or  anodal  diifusion,  is  not  reliable,  and  often 
acts  badly.  Morphin  should  only  be  given  by  the  physician  or  a  com- 
petent nurse.  It  is  well  if  the  patient  can  be  kept  in  ignorance  of  the 
nature  of  the  drug,  owing  to  the  tendency  which  is  especially  strong 
in  these  neurotic  cases  to  the  acquirement  of  the  opium-habit.  The 
use  of  electricity  is  more  often  disappointing  than  otherwise.  The  posi- 
tive pole  to  the  tender  area,  wuth  three  to  ten  milliamperes  uninterrupted 
current  for  ten  minutes,  sometimes  allays  the  pain.     The  current  should 


630  8YMPT03IATIC  DISORDERS. 

commence  from  zero,  slowly  increase  until  felt  as  "  warm,"  and  finally 
decrease  in  the  same  way,  without  shock.  The  use  of  strychnin  hypo- 
dermatically  in  large,  repeated,  and  increasing  doses,  the  patient  being 
meanwhile  confined  to  bed  and  carefully  fed,  as  advocated  by  Dana,  is 
a  promising  line  of  treatment.  Commencing  with  -^  of  a  grain  every 
four  hours,  doses  of  i  of  a  grain  are  sometimes  well  tolerated.  It  is  well 
to  employ  general  massage  at  the  same  time,  and,  as  the  pain  subsides, 
massage  and  vibrations  to  the  tender  area  and  sensitive  points  may  be 
added  with  advantage.  As  a  last  resort,  operation  may  be  advised,  but 
only  when  a  careful,  intelligent,  and  persistent  use  of  general  and  spe- 
cial measures  has  failed,  or  there  is  evidence  of  organic  changes  in  the 
nerve  or  nuclei.  There  are  three  general  varieties  of  operations  upon 
the  trifacial :  (1)  Those  for  the  purpose  of  section,  exsection,  stretching, 
divulsing,  or  twisting  out  the  various  branches  at  some  point  below  the 
floor  of  the  skull ;  (2)  those  directed  to  enucleation  of  the  trifacial  gan- 
glion ;  (3)  division  of  the  sensory  root  of  the  fifth  above  the  ganglion. 
Operations  upon  the  ganglion  are  very  difficult  and  dangerous.  Fre- 
quently, the  eye  on  the  same  side  has  been  lost.  The  operation  of 
Horsley,  in  which  the  skull  is  opened  and  the  sensory  root  divided 
beneath  the  pons,  is  much  less  mutilating  and  disfiguring,  but  seems  to 
be  attended  by  danger  to  life.  After  root  divisions  the  fibers  degenerate 
upward,  1  thereby  producing  a  permanent  result.  This  operation  is 
worthy  of  more  frequent  employment,  in  spite  of  its  difficulty  and 
danger.  Spiller  and  Frazier  ^  modify  this  proceeding  by  reaching  the 
sensory  root  above  the  ganglion  but  outside  the  skull,  the  operation 
being  carried  out  precisely  on  the  lines  of  excision  of  the  ganglion. 
Operations  on  the  branches  below  the  ganglion  usually  give  temporary 
freedom  from  pain,  but  relapses  are  common  in  the  same  or  in  adjoining 
branches.  (For  details  the  student  is  referred  to  surgical  works.) 
Fortunately,  w^itli  proper  systemic  and  local  treatment  these  severe 
operations  are  very  rarely  demanded.  As  the  slighter  ones  of  neurec- 
tomy, etc.,  occasionally  give  permanent  relief,  they  should  be  tried  first. 


CHAPTER  II. 
DISORDERS  OF  SLEEP. 

The  disorders  and  disturbances  of  sleep,  while  mainly  symptomatic, 
in  some  instances  reach  an  important  development  and  almost  attain  the 
dignity  of  a  disease.  Sleep  may  be  defined  as  a  recurring,  necessary 
state  of  lessened  muscular,  mental,  and  organic  activity,  attended  by 
comparative  unconsciousness  of  surroundings,  l^o  physical  or  mental 
function  is  absolutely  abeyant.  Respiration,  circulation,  metabolism, 
catabolisra,  muscular  movements,  and  dreams  demonstrate  the  persist- 
ence of  functional  activities.  Entirely  dreamless  sleep  probably  does 
not  occur.  Sleep,  therefore,  is  a  composite  which  may  be  variously 
disintegrated.     Sleep-walking,  talking  in   the   sleep,  nightmare,  night- 

1  L.  F.  Barker,  "Jour.  Am.  Med.  Association,"  May  5,  1900. 

2  "  Phila.  Med.  Jour.,"  Dec.  14,  1901,  and  ihid.,  Oct.  25,  1902. 


DISORDERS   OF  SLEEP. 


631 


terrors,  and  nocturnal  enuresis,  may  be  considered  as  localized  or  partial 
sleeplessness.  In  somnambulism  the  motor  apparatus  is  awake,  as  it  is  in 
night-terrors.  In  enuresis  Ave  have  a  somnambulism  of  the  lumbar  cord, 
to  adopt  a  term  from  the  French.  Of  the  physiology  of  sleep,  though 
it  is  more  necessary  to  life  than  food,  we  know  comparatively  little. 

Physical  Features  of  Sleep. — In  sleep  there  is  museular  relaxation. 
The  lids  are  lowered  over  the  upturned  eyeballs ;  the  expression  is  one 
of  repose.  Respiration  is  slower  and  less  deep.  Mosso  states  that  the 
amount  of  air  inspired  by  a  normal  man  during  sleep  is  one-seventh 
of  that  used  during  similar  periods  of  quiet  wakefulness.  Breathing 
is  distinctly  thoracic  in  character,  the  diaphragm  acting  but  slightly ; 
inspiration  is  more  prolonged  and  the  respiratory  pause  is  absent.  There 
is  a  decrease  in  carbonic  acid  elimination  and  an  increase  in  the  absorp- 
tion of  oxygen.  The  circulation  presents  important  modifications.  The 
pulse  is  less  rapid.  The  superficies  of  the  body  has  an  increased  vascu- 
larity and  is  often  reddened  ;  there  is  lowered  arterial  pressure  and  a 


5 

800 


700 
600 

soo 

300 
ZOO 
700 


m 


H0UR5  0S     IS)     /.5    2,0    Z5    3.0    AS     ^0   Jf.S    S.0    S.S     6,0     bjs     7.0    7.S    7.8 

Fig.  268.— Curve  illustrating  strength  of  auditory  stimulus  (falling  ball)  necessary  to  waken  a 
sleeping  person.  The  hours  are  marked  below,  and  the  tests  were  made  at  half-hourly  intervals.  The 
curve  shows  that  the  height  from  which  the  ball  must  be  dropped  reaches  its  maximum  at  the  end 
of  the  first  hour  (KohlschiitterJ. 


smaller  central  circulation.^  The  brain  is  comparatively  anemic.  The 
arterial  changes  take  place  in  a  precise  way,  increasing  with  some 
rapidity  during  the  first  hour,  maintaining  a  maximum  for  an  hour  or 
two,  and  then  gradually  decreasing  to  the  waking  moment.  Such 
curves  have  been  shown  by  the  plethysmograph  and  correspond  fairly 
well  to  those  indicating  the  depth  of  sleep  as  demonstrated  by  Kohl- 
schiitter  and  others.  In  accordance  with  universal  experience,  the  first 
few  hours  of  sleep  are,  therefore,  most  profound,  refreshing,  and  valu- 
able. The  thorax  and  limbs  actually  increase  in  size  during  sleep, 
owing  to  the  circulatory  conditions ;  and  we  readily  comprehend  the 
increased  activity  of  the  sl'in,  the  tendency  to  night-s^ceafs,  and  the  ease 
with  which  one  is  chilled  during  sleep.  Lombard,  Rosenbach,  and 
others  have  observed  that  the  muscle  reflexes  are  exaggerated  just  before 
1  Howell,  "Jour,  of  Experimental  Med.,"  1897. 


632  SYMPTOMATIC  DISOBDEBS. 

and  during  the  early  moments  of  sleep,  but  gradually  subside,  and  the 
knee-jerk  may  even  disappear.  Slight  disturbances  tending  to  awaken 
the  individual  are  attended  by  a  corresponding  increase  in  the  reflex 
activity  and  the  central  circulation.  We  are  all  familiar  with  sudden 
startings  when  dropping  off  to  sleep — a  manifestation  of  the  increased 
reflex  excitability,  constituting  one  of  the  epiphenomena  of  sleep. 
The  pupih  are  contracted  in  proportion  to  the  profoundness  of  the  sleep. 

Requirements  for  Sleep. — Individuals  vary  greatly  in  the  amount 
of  sleep  required,  and  at  different  ages  there  are  different  needs.  While 
some  few  adults  find  four  or  five  hours  sufficient,  the  great  majority 
demand  eight  or  ten.  There  are  also  temperamental  differences  and 
many  variations,  the  result  of  habit  and  circumstances.  Crichton  Brown 
says  that  at  four  years  twelve  hours'  sleep  are  needed  ;  at  fourteen  years, 
ten  hours ;  at  seventeen,  nine  and  one-half  hours ;  then  seven  or  eight 
hours  during  adult  life.  In  old  age  continuous  sleep  is  rare,  and  the 
requirement  is  less  ;  but  frequent  naps  and  dozing,  by  day  as  well  as  at 
night,  maintain  a  fair  average.  Infants  may  sleep  most  of  the  twenty- 
four  hours.  More  sleep  is  required  in  cold  than  in  temperate  or  warm 
countries. 

Conditions  Favoring  Sleep. — A  cool,  dark,  quiet,  well-ventilated 
room,  a  comfortable  bed,  and  adequate,  not  excessive,  covering,  are 
conducive  to  sleep.  A  preparatory  period  of  sleepiness  is  natural,  and, 
in  cases  of  insomnia,  must  be  cultivated.  Active  emotions,  mental 
worries,  intense  thought,  cold  extremities,  or  a  chilled  skin  defeat  the 
rearrangement  of  the  circulation,  on  which  so  much  depends.  No 
physical  function  is  so  readily  disturbed  as  sleep.  If  a  person  is 
awakened  at  an  unusual  hour  several  nights  in  succession,  he  tends  to 
establish  a  habit  of  awakening  at  that  hour.  Habit  is  all-powerful, 
both  for  good  and  evil,  in  this  matter.  Regular  hours  for  retiring  and 
awaking  are  most  important.  The  use  of  hypnotics  to  put  patients  to 
sleep  regularly  for  a  few  nights  do  good  mainly  by  reestablishing  the 
natural  initiative. 

Disturbances  of  sleep  are  (1)  those  presenting  a  deficiency,  and 
(2)  those  marked  by  a  morbid  increase  of  sleep. 


WAKEFUL  DISORDERS  OF  SLEEP. 

Insomnia. — Insomnia  is  a  symptomatic  condition,  marked  by  more 
or  less  inability  to  sleep  the  individual's  usual  required  length  of  time. 

Etiology. — The  causes  of  sleeplessness  are  numerous.  Practically, 
every  deviation  from  health  is  marked  by  disturbance  of  sleep ;  but^in 
many  instances,  once  a  bad  sleep  habit  is  established,  it  tends  to  persist, 
and  may  be  the  chief  complaint  of  the  patient.  Many  persons  are  heredi- 
tarily poor  sleepers.  In  such  instances  every  trivial  sound  or  unusual 
circumstance — a  light,  an  odor,  ajar,  or  even  the  discontinuance  of  a  cus- 
tomary noise  or  light — may  arouse  them.  Hunger,  over-feeding,  indi- 
gestion, constipation,  intestinal  worms,  litheraia,  uremia,  various  drugs, 
tea,   cofffee,   tobacco,   alcoholism,   fevers  of  all  sorts,   malaria,  syphilis, 


DISORDERS   OF  SLEEP.  633 

lead-poisoning,  cerebral  hyperemia  or  anemia,  as  from  cardiac  disease 
or  diathetic  states,  psychic  distnrbances,  discomfort,  pain,  nenrasthenia, 
grief,  worry,  old  age,  mental  })rcoccupation,  and  intense  stndy  are  among 
the  principal  inciting  causes  of  sleeplessness. 

Symptoms. — Some  patients  readily  fall  asleep,  but  shortly  awake, 
and  are  then  sleepless  the  balance  of  the  night,  or  merely  secure  fitful 
periods  of  sleep.  Others  spend  several  hours  getting  to  sleep,  and  may 
then  rest  fliirly  well.  Still  others  complain  of  broken  sleep,  the  night 
being  passed  in  intervals  of  sleep  and  wakefulness,  which  may  be  quite 
uniform  in  a  given  instance.  As  a  rule,  patients  troubled  with  insomnia 
are  disposed  to  exaggerate  the  amount  of  sleeplessness,  and  it  is  a  common 
experience  to  find  such  patients  sleeping  soundly  at  times,  or  even  for 
much  of  the  night,  if  they  are  put  under  watch.  Much  loss  of  sleep 
manifests  itself  in  a  haggard,  weary  air,  and  in  lessened  muscular  and 
mental  force.  Appetite,  digestion,  energy,  courage,  and  good  nature 
are  diminished.  The  patient  loses  weight,  and,  in  cases  of  absolute 
sleeplessness,  the  loss  may  equal  that  due  to  deprivation  of  food.  The 
eyes  lose  their  clearness  and  look  dull,  and  the  sclerotic  may  be  con- 
gested. The  tongue  is  coated,  constipation  may  be  present,  and  the 
entire  organism  is  deranged. 

Treatment. — The  treatment  of  the  symptom  insomnia  implies  the 
management  of  the  basic  condition  of  which  it  is  a  manifestation.  All 
hereditary,  digestive,  toxic,  circulatory,  nervous,  and  reflex  causes  must 
be  systematically  investigated.  The  examination  of  a  patient  complain- 
ing of  insomnia  omits  nothing.  Very  frequently,  modes  of  living,  and 
especially  bad  sleep-habits,  must  be  corrected  before  any  improvement 
is  secured.  The  physical  state  often  requires  to  be  thoroughly  well 
reestablished  by  baths,  proper  diet,  exercises,  and  good  hygiene.  Atten- 
tion at  once  falls  upon  the  conditions  favoring  sleep,  as  previously  outlined. 
The  patient  must  be  instructed  in  the  importance  of  these  minutiae,  and 
not  expect  to  secure  complete  relief  by  a  few  doses  of  medicine.  As 
adjuvants,  a  warm  bath,  taken  quietly  at  bedtime,  not  followed  by 
stimulating  frictions,  is  conducive  to  sleep.  A  cold  pack  or  an  alcohol 
rub  acts  well  in  some  cases.  The  stomach  should  not  be  empty.  A 
glass  of  hot  milk,  or  milk  and  water,  or  malted  milk,  or  hot  lemonade, 
or  even  of  hot  water,  acts  beneficially  in  decongesting  the  head  in  cases 
not  anemic.  With  the  hot  bath  it  favors  the  dilatation  of  the  cutaneous 
vessels,  and  establishes  the  circulatory  conditions  found  in  natural  sleep. 
In  the  same  way  a  pint  of  beer  not  only  starts  the  abdominal  organs, 
but  flushes  the  skin.  Large  doses  of  whisky  are  never  advisable, 
although  sometimes  efficient  for  a  night  or  two.  Anemic  cases  require 
cardiac  stimulants  and  blood-makers. 

Any  drug  that  sufficiently  masters  the  organism  to  produce  sleep  is 
a  dangerous  remedy,  and  should  be  used  with  circumspection,  and  only 
as  a  last  resort.  Of  all  the  hypnotics,  chloral  alone  is  uniformly  reli- 
able. In  cases  attended  with  much  nervousness  it  is  decidedly  assisted 
by  the  addition  of  sodium  bromid  in  equal  amount.  The  administration 
of  hypnotics  should  be  done  with  a  definite  purpose.  It  is  important  to 
exhibit  whichever  one  is  selected  at  such  time  that  its  systemic  effect 


634  SY3IPT0MATIC  DISORDERS. 

may  be  operative  when  the  sleeplessness  is  clue.  In  cases  experiencing 
difficulty  in  getting  to  sleep  chloral  may  be  given  thirty  minutes  before 
retiring.  Cases  awakening  at  one  or  two  o'clock  may  be  given  trional, 
in  dry  powder,  at  bedtime,  as  its  action  is  liable  to  be  delayed  for  a  few 
hours.  A  sufficient  dose  should  be  used  to  have  a  decided  effect,  repeated 
several  nights,  if  its  action  meets  the  requirements,  and  then  discontinued. 
In  some  instances  five-grain  doses  every  two  hours  after  mid-day  act 
much  better  than  a  large  dose  at  bedtime.  If  the  underlying  cause  has 
been  corrected,  the  proper  routine  will  thereby  be  reestablished  in  a  few 
nights.  Finally,  some  cases  only  yield  after  a  complete  change  of  scene. 
An  ocean  or  lake  voyage  is  especially  valuable,  as  it  is  devoid  of  ex- 
hausting excitement  and  sight-seeing. 

Somnambulism. — In  sleep-walking  the  individual  acts  his  part  of 
a  dream.  The  motor  apparatus  is  awake  and  responsive  to  the  mind. 
It  is  sleep  with  motor  automatic  activity,  and  presents  a  peculiar 
increase  of  the  subjective  powers  of  the  affected  person.  There  is 
often  great  keenness  of  touch  and  analgesia  combined.  The  special 
senses  may  be  active  or  not,  but  the  patient  only  takes  cognizance  of 
those  things  which  pertain  to  the  dream-story.  Usually,  the  pupils  do 
not  respond  to  light,  and  the  face  has  a  blank,  apathetic  appearance. 
The  eyes  may  be  open  or  closed.  The  sleep-walker  has  no  subsequent 
waking  recollection  of  his  somnambulistic  acts ;  but  these  may  be 
revived  or  repeated  in  a  subsequent  attack.  Talking  in  the  sleep  is  a 
minor  degree  of  somnambulism,  and  the  state  of  double-consciousness 
may  be  considered  as  its  largest  development. 

Somnambulism  may  ordinarily  be  considered  as  a  neurotic  stigma, 
and  is  commonly  encountered  in  those  of  a  neuropathic  heredity. 
Puberty  is  the  ordinary  age  for  its  appearance,  and  both  sexes  are  then 
about  equally  affected.  Later  in  life  there  are  more  female  than  male 
cases.  The  individual  attack  is  often  traceable  to  some  mental  prece- 
dent condition.  Even  the  suggestion  of  sleep-walking,  in  the  discus- 
sion of  the  subject,  has  led  to  its  appearance.  In  other  cases  the 
patient  carries  out  in  sleep  the  line  of  action  on  which  he  had  been 
intent  before  retiring.  In  most  cases  presenting  repeated  attacks  there 
is  a  similarity  of  action  in  all  of  them,  or  one  attack  may  continue  the 
action  of  its  predecessor. 

The  treatment  of  the  condition  should  be  broad  enough  to  cover  the 
neuropathic  make-up  of  the  patient,  and  is  most  successful  in  proportion 
as  it  is  directed  to  the  mental  element  in  the  disturbance.  If  the 
patient  takes  with  him  to  bed  a  firm  intention  not  to  walk,  it  is  often 
sufficient  to  inhibit  the  attack.  In  nervous  subjects  of  impaired  self- 
control  a  vigorous  suggestion,  that  will  be  operative  during  sleep,  must 
be  implanted.  This,  in  children,  may  be  accomplished  by  a  system  of 
rewards  or  deprivations,  by  a  cold  spinal  douche  at  bedtime,  associated 
with  the  suggestion  that  it  is  to  prevent  walking  during  the  night,  or 
by  an  emphatic  admonition  from  a  respected  source.  The  individual 
attack  may  be  brought  to  an  end  by  a  dash  of  cold  water,  or  a  sharp 
jjuff  of  breath  in  the  face,  or  by  firm  Y)ressure  over  the  supraorbital 
foramina.     So  rude  a  shock  may  be  curative,  but  in  highly  nervous 


DISORDERS  OF  SLEEP.  635 

children  is  to  be  used  witli  caution.  In  adult  cases,  with  frequently 
repeated  attacks,  any  plan  of  treatment  is  likely  to  fail,  and  in  some 
instances  nightly  precautions  are  necessary  to  guard  against  accidents. 

Dreams. — Dreaming  is  perfectly  physiological.  As  already  stated, 
it  is  probable  that  dreamless  sleep  does  not  occur.  Only  those  dreams, 
however,  are  remembered  that  are  particularly  vivid  or  occur  during 
light  sleep,  the  ordinary  condition  after  the  third  hour.  In  numerous 
experiments  it  has  been  found  that  sleepers,  suddenly  and  unexpectedly 
aroused,  can  always  give  an  account  of  the  interrupted  dream.  Dreams, 
however,  have  a  considerable  medical  importance.  In  lowered  nervous 
or  physical  states  the  sleep  is  not  profound,  and  the  patient  complains  of 
dreaming  constantly.  The  nature  of  the  dreams  has  a  general  relation 
to  the  physical  and  mental  status.  Only  the  well  have  contented,  happy 
dreams.  Neurasthenics,  hysterics,  and  melancholiacs  are  tormented  by 
troubled  dreams  of  an  unhappy,  depressing  character.  Neurasthenics 
and  hysterics  are  prone  to  have  some  particular,  formulated  dream  that 
occurs  several  times  in  a  night  or  on  different  nights.  The  influence  of 
a  terrifying  dream  in  hysteria  may  equal  a  severe  mental  shock  in  the 
waking  moments,  and  may  be  the  basis  of  a  hysterical,  fixed  idea,  leading 
to  paralysis,  anesthesia,  contracture,  or  assertion  of  attempts  upon 
chastity  (Janet). 

In  some  nervous  conditions  the  dream  state  is  projected  into  the 
waking  state  for  a  few  moments,  or  for  a  longer  time.  In  hysteria  the 
features  of  the  dream  may  then  persist  for  an  hour  or  more,  constituting 
a  delirious  accident.  It  is  a  sort  of  somnambulism,  but  with  greater 
mental  and  physical  activity.  Or  the  dream  may  evoke  a  convulsive 
crisis.  Of  the  same  nature,  perhaps,  is  sleep-drmikenness,  or  somnolentia, 
in  which  a  person,  on  being  suddenly  awakened  from  deep  sleep,  is 
apparently  maniacal,  and  may  do  acts  of  violence. 

In  pavor  nocturnus,  commonly  called  night-terrors,  and  occurring 
only  in  children,  the  little  patient  awakes  in  vague,  wild  alarm  one  or 
two  hours  after  going  to  sleep.  The  child  screams  in  terror,  clings  to 
its  mother,  but  apparently  fails  to  recognize  any  one,  and  can  not  be 
quieted  or  reassured.  After  a  few  minutes  or  more  the  excitement 
spontaneously  subsides  and  the  child  returns  to  sleep  without  recollec- 
tion of  the  attack  in  the  morning.  During  the  frenzied  terror  the 
patient  may  run  from  the  room,  or  climb  upon  the  furniture,  in  a  wild 
effort  to  escape  something.  Often  the  cries  imply  a  fear  of  being  caught 
by  some  one  or  by  wild  animals. 

True  pavor  nocturnus  is  of  somewhat  serious  import,  as  it  indicates 
an  unstable  nervous  constitution,  and  is  a  frequent  item  in  the  early 
history  of  epileptics.  Some  writers  consider  it  a  true  neurosis,  and,  at 
least,  it  is  a  stigma  of  degeneracy.  It  is  often  apparently  induced  by 
respiratory  difficulty  dependent  upon  faucial  adenoids,  bronchitis,  laryn- 
gitis, weak  heart,  or  general  asthenia.  In  mild  form  it  may  only  suggest 
nightmare  or  incubus,  which  is  a  vivid  dream,  usually  traceable  to  some 
physical  condition  or  previous  terrifying  experience.  Indigestion,  bad 
ventilation,  or  mental  shocks,  fright,  worry,  etc.,  give  rise  to  nightmares 
attended  by  a  feeling  of  a  great  weight  on  the  chest,   suffocation  or 


636  SYJIPTOJIATIC  DISOEDEES. 

falling.  Ordinarily,  at  such  moments  the  patient  suspends  respiration, 
or  makes  distressed  inspiratory  noises  and  awakens  with  a  start. 

Nocturnal  enuresis  is  a  common  disorder  in  weakly  and  neurotic 
children.  Neurasthenics,  hysterics,  epileptics,  and  the  entire  range  of 
neuropaths  give  abundant  testimony  on  the  subject  of  bed-wetting.  In 
certain  instances  it  undoubtedly  is  an  automatic  action,  a  partial  som- 
nambulism. The  patient  dreams  he  is  passing  water,  and  voids  his  urine 
accordingly.  The  same  mechanism  may  operate  in  the  more  frequent 
form.  Parents  report  that  when  this  occurs  under  obser^'ation  the 
bladder  acts  forcibly,  and  the  stream  is  propelled  with  vigor.  It  is  not 
a  mere  sphincteric  relaxation,  as  is  sometimes  alleged.  Such  children, 
if  taken  up  at  night  and  made  to  urinate,  may  repeat  the  act  almost 
immediately  upon  being  put  back  to  bed,  perhaps  through  suggestion. 
It  is  probable  that  slight  distention  of  the  bladder,  or  the  presence  of  a 
drop  or  two  of  urine  in  the  vesical  end  of  the  urethra,  gives  rise  to  sensa- 
tions which  set  up  a  chain  of  ideas  eventually  leading  to  the  urinary  act. 
It  is  definitely  proven  that  various  external  stimuH — as  sounds,  voices, 
lights,  etc. — may  be  partially  apprehended  Idv  the  sleeper  and  woven 
into  his  dreams,  materially  modifying  their  trend.  Internal  sensations 
are  no  less  liable  to  act  in  the  same  manner,  and  are  generally  accredited 
of  doing  so  in  nightmare. 

The  management  of  nocturnal  enuresis  demands  attention  to  several 
factors  :  First,  the  general  condition  of  health  ;  second,  the  reduction 
of  nervous  excitability  ;  third,  the  prevention  of  a  large  vesical  accumu- 
lation ;  fourth, — and  perhaps  the  most  important  of  all,  as  in  somnamlju- 
lism, — the  establishment  of  a  definite  idea  of  self-control.  It  is  well  to 
withhold  liquids  toward  the  evening,  and  to  have  the  child  thoroughly 
evacuate  the  bladder  at  bedtime.  Elevation  of  the  foot  of  the  bed  by 
several  inches,  to  gravitate  the  urine  from  the  neck  of  the  bladder,  has 
been  strongly  recommended  by  ^Mendelssohn.  Belladonna  reduces  vesi- 
cal irritability,  and  the  urine  should  be  rendered  unirritating.  Local 
disturbance  in  bladder  and  urethra  must  be  removed  and  worms  ex- 
pelled. Finally,  a  strong  mental  impression  is  of  the  greatest  value.  For 
instance,  Prendergast  ^  cured  seventy -five  out  of  eighty  cases  in  a  boys' 
orphanage  within  a  short  period  of  time  by  giving  them  a  cold  spinal 
douche,  followed  by  a  quick  rubbing-down  just  before  getting  into  bed. 
Nothing  else  whatever  was  done,  and  the  five  remaining  cases  were  much 
improved.  In  some  cases  the  first  douche  had  the  necessary  effect,  and 
the  mind  remained  on  guard. 


SOMNOLENT  DISORDERS  OF  SLEEP. 

The  second  group  of  sleep  disorders  comprises  those  marked  by 
somnolence,  or  l)y  an  irresistible  tendency  to  sleep. 

Narcolepsy  is  a  condition  in  which  the  patient  repeatedly  goes  to 
sleep  during  the  day.  The  tendency  is  irresistible,  and  the  morbid 
sleep  may  last  a  few  minutes  or  several  hours.  It  furnishes  one  of  the 
1  '-Xew  York  Med.  Jour.."  Julv  11.  1S96. 


DISOIWEES   OF  SLEEP.  637 

accidents  of  liysteria,  and  may  be  dependent  npon  drn^s,  brain  disease, 
gont,  obesity,  uremia,  diabetes,  and  sypiiilis.  Some  neurotic  families 
present  a  number  of  instances  of  narcolepsy,  associated  or  alternating 
with  severe  neuroses,  mainly  hysteria  and  epilepsy.  It  may  be  an  epi- 
leptic equivalent,  and  many  cases  also  present  epilepsy.  It  should 
always  suggest  the  possibility  of  epilepsy  or  hysteria  if  defective  nutri- 
tion and  the  systemic  states  mentioned  can  be  excluded.  In  some 
instances  ocular  fatigue,  due  to  refractive  errors,  seems  to  he  the  start- 
ing-point for  the  attacks,  wdiich  are  overcome  by  appropriate  glasses. 
In  some  instances  the  sleep  in  such  attacks  is  disturbed,  and  the  patient 
may  have  vivid  dreams  and  talk  in  a  flighty  manner.  In  other  cases,  as 
in  epilepsy,  the  patient  is  comatose  and  can  not  be  aronsed.  In  the  ma- 
jority of  cases  the  sleep  is  deep  and  no  dream  recollections  are  obtainable. 

Treatment  depends  upon  deciphering  and  removing  the  cause,  and 
then  breaking  up  the  habit.  For  this  purpose  cafFein  and  nitroglycerin 
or  nitrate  of  aniyl,  to  control  the  cerebral  circulation,  are  available. 

Sleeping  Sickness. — On  certain  African  coasts  the  natives  are 
atfected  by  a  supposedly  parasitic  disease — (filaria?).  Somnolence 
appears  at  intervals  and  gradually  increases,  until  the  patient  sleeps 
steadily,  at  first  arousing  sufficiently  to  take  food,  and  finally  not  awak- 
ing under  any  stimulus.  In  two  cases  carefully  observed  l^y  Mott,  ^  a 
chronic  diffuse  leptomeningitis  and  encephalomyelitis  were  found,  but  no 
infectious  organism.  Death  usually  results  from  inanition  in  four  or 
five  months,  but  patients  have  lived  for  two  or  three  years.  Treatment 
seems  unavailing. 

Trance,  catalepsy,  and  ecstacy  are  hysterical  accidents — fractional 
hysterical  convulsions  extended  into  status.  They  are  described,  with 
their  treatment,  in  the  discussion  of  Hysteria. 


SLEEP  PALSIES. 

Persons  with  disordered  systemic  conditions — as  in  anemia,  gout, 
diabetes,  women  at  the  menopause,  excessive  users  of  tobacco,  etc. — may 
awake  with  benumbed  extremities.  The  hands  and  feet  are  most 
affected,  giving  origin  to  the  term  acroparesthesia.  The  sensations  are 
described  as  pricking  and  numbness,  as  being  "  asleep,"  and  some 
cramping  and  decided  pain  may  occur.  A  loss  of  power  is  noted  if  the 
condition  is  marked.  The  disturbance  lasts  a  few  minutes  or  an  hour, 
and  is  usually  relieved  by  friction  and  exercising  the  members.  Less 
frequently  one  limb  only  is  affected,  or  both  limbs  on  one  side.  This 
affection  may  occur  nightly  for  months  and  years,  and  appear  during 
the  day  also  if  the  patient  fall  asleep.  Its  treatment  is  that  of  the 
underlying  state. 

In  sleep,  especially  the  profound  sleep  of  drunkenness  or  the  coma 
of  anesthesia,  pressure  on  a  nerve  may  set  up  a  neuritic  palsy.  This 
is  particularly  common  in  the  musculospiral,  but  in  operations  on  the 
perineum  and  pelvic  contents  the  lithotomy  position  is  capable  of  injuri- 
ously stretching  the  sciatic.  The  brachial  plexus  may  be  injured  by 
1  "Br.  Med.  Jour.,"  Dec.  16,  1899. 


638  SYIMPTOMATIC  DISORDERS. 

elevating  the  arm  too  forcibly  in  operation  on  the  breast,  or  by  the 
anesthetizer.  These  are  hardly  to  be  called  sleep  palsies,  but  are 
definite  accidents  occurring  during  sleep. 

Anemic  neurasthenic  patients  sometimes  have  difficulty  in  opening 
the  eyes  in  the  morning,  but  if  the  lids  are  once  raised  by  the  finger, 
they  tend  to  remain  open.  The  symptom  is  called  sleep  ptosis,  is 
usually  transient,  and  commonly  passes  away  with  the  myasthenia  of 
which  it  is  part.  This,  or  a  similar  condition,  occurs  as  a  part  of  my- 
asthenia gravis  or  pseudobulbar  paralysis. 

HYPNOTISM. 

Hypnotism  is  an  artificial,  morbid,  sleep-like  condition  produced  in 
susceptible  persons  by  various  methods.  In  it  the  complex  of  sleep  is 
more  or  less  disaggregated.  Attention  within  a  limited  field  and  auto- 
matic motor  activity  may  be  retained,  but  mental  initiative,  volition, 
and  judgment  are  much  impaired.  The  acts  and  circumstances  of  well- 
marked  hypnotic  conditions  can  not  be  recalled  by  the  subject  unless 
the  hypnosis  is  revived.  It  is,  therefore,  a  state  of  subconsciousness  or 
double  consciousness.  Different  experimenters  find  varying  proportions 
of  susceptible  individuals.  The  sexes  are  about  equally  hypnotizable. 
Those  of  mediocre  self-consciousness,  those  accustomed  to  unquestion- 
ingly  obey, — hence,  children  and  some  hysterics, — rare  the  most  ready 
subjects.  A  great  deal  depends  upon  the  preparatory  conditions  and 
the  belief  or  skepticism  of  the  patient.  In  those  places  where  daily 
stances  of  hypnotism  are  held  and  the  subject  is  introduced  into  an 
atmosphere  of  faith  and  observes  the  process  in  others,  success  in  the 
method  is  naturally  greatest.  Experience  on  the  part  of  the  hypnotizer 
is  also  an  important  factor.  The  whole  matter  consists  of  building  up 
an  expectant  attention.  Low-grade  idiots,  most  of  the  insane,  and  many 
hysterics,  incapable  of  exercising  continuous  attention,  are  not  hypnotiz- 
able by  ordinary  methods.  The  state  is  purely  subjective  to  the  one 
operated  upon.  After  a  person  has  once  been  hypnotized,  he  subse- 
quently more  readily  enters  hypnosis,  and  finally  the  condition  is  pro- 
duced almost  at  a  hint.  In  extreme  cases  it  may  be  automatically 
evoked  by  anything  which  suggests  the  method  employed  in  the  given 
case,  and  the  subject  becomes  the  puppet  of  a  trivial  sound  or  flash  of 
light.  During  hypnosis  there  is  a  high  degree  of  suggestibility,  so  that 
the  subject  unquestioningly  accepts  the  dictum  of  the  operator.  In 
somnambulism  the  special  senses  and  general  sensibility  may  be  extremely 
acute  or  entirely  blunted,  responding  only  along  the  various  lines  of  the 
hypnotic  field  of  activity.  Autohypnosis  is  also  possible,  and  is  a  com- 
mon trick  of  East  Indian  fakirs  and  dime  museum  tricksters  in  this 
country. 

Methods  of  Hypnotizing. — After  the  subject  is  prepared  by  ex- 
ample or  explanation  and  his  co5peration  secured,  the  most  common 
plan,  that  of  Braid,  is  to  cause  ocular  fatigue  by  having  the  patient  fix 
the  eyes  in  unwinking  gaze  upon  a  small,  bright  object  held  about  six 
inches  distant  and  above  the   ordinary  line  of   vision.     This    shortly 


DISORDERS  OF  SLEEP.  639 

produces  a  feeling  of  fatigue  iu  the  ocular  muscles,  the  eyes  water,  the 
lids  tremble,  and  the  operator,  by  suggesting  sleep,  adds  to  the  mental 
impression  of  drowsiness.  Passes  of  the  band  over  the  liead  or  down 
the  limbs  may  be  added.  Their  soothing  effect  is  well  known,  and  soon 
the  eyes  close,  or  the  lids  are  pressed  down  by  the  operator,  who  enjoins 
the  patient  to  "  sleep,  sleep  soundly,  deeper  yet,  deep  sleep,"  etc.  Four 
or  five  minutes  may  be  required  for  this  performance,  the  patient  being 
placed  in  a  reclining  or  comfortable  attitude  for  sleep.  At  this  point 
the  subject  is  firmly  and  authoritatively  told  that  his  eyes  are  closed, 
that  he  is  asleep,  that  he  can  not  open  his  eyes.  Tiie  operator  mav 
start  the  subject's  hands  in  rotation  and  command  him  to  continue  the 
movement,  asserting  tliat  he  can  not  stop  until  ordered,  etc.  Other 
methods  contain  the  same  elements  of  suggestion  and  are  aided  by  the 
operatoi*'s  voice  in  a  similar  manner.  Thus,  continuous  gentle  pressure 
on  the  eyeballs,  passes,  and  stroking,  monotonous  sounds,  fixing  the 
attention,  or  gazing  fixedly  at  small  revolving  mirrors  (Luys),  the 
patient  meanwhile  sitting  in  a  darkened  room,  are  among  the  methods 
frequently  used.  A  loud  sound  or  a  vivid  flash  of  light,  after  due  prep- 
aration, may  throw  the  subject  at  once  into  deep  hypnosis  (Charcot). 
Bernheim  fixes  the  patient's  gaze  with  his  own  and  suggests  sleep  : 
'*  Sleep  is  approaching,  your  limbs  are  feeling  warm  and  gently  tingling, 
your  eyelids  are  heavy,  you  are  going  to  sleep ;  you  are  sleeping,  sleep 
soundly,"  etc.  The  subject  is  aroused  by  command,  by  a  puff*  of  air 
in  the  face,  or  by  stroking  the  head.  If  left  to  himself,  he  sponta- 
neously emerges  from  the  hypnosis  after  a  variable  time,  a  few  minutes 
or  an  hour  or  two. 

The  hypnotic  state  varies  in  intensity  from  slight  torpor  to  somnam- 
bulistic automatism.  Only  a  small  percentage  of  subjects  can  be  put 
into  the  deepest  phase  ;  and  it  is  rarely  required,  as,  for  purposes  of 
therapeutic  suggestion,  the  lighter  phases  are  quite  sufficient.  Charcot 
divided  the  hypnotic  state  into  three  phases — the  lethargic,  the  cataleptic, 
and  that  of  somnambulism.  In  the  first  the  subject  is  as  if  asleep, 
without  changes  of  respiration,  pulse,  or  temperature.  There  is  usually 
some  analgesia,  but  the  operator's  voice  is  heard  and  the  subject  replies 
to  questions.  In  the  cataleptic  stage  the  limbs  retain  the  position  given 
them,  or,  if  set  in  motion,  continue  the  movement  indefinitely,  analgesia 
is  complete,  and  commands  are  obeyed  within  the  cataleptic  range.  In 
somnambulism  the  subject  is  automatically  responsive  in  every  way  to 
the  operator,  whom  alone  he  sees,  hears,  or  obeys,  unless  otherwise  in- 
structed. Suggestions  are  implicitly  accepted,  regardless  of  their  non- 
sensical or  irrational  character,  and  commands  that  do  not  contravene 
deep-seated  moral  convictions  are  unquestioningly  executed.  Subse- 
quently, the  subject  has  no  recollection  of  his  automatic  acts  or  of  the 
conditions  under  which  they  were  performed,  but,  rehypnotized,  can 
readily  reproduce  them. 

Uses  of  Hypnotism. — In  spite  of  the  extravagant  claims  for  the 
therapeutic  value  of  hypnotism,  it  is  as  yet  of  very  little  service  to  the 
physician.  Kow  and  again  a  minor  operation  may  be  done  under  its 
influence,  saving  the   slight  risk  of  surgical  anesthesia,  or  by  its  aid  a 


640  SYMPT03IATIC  DISORDERS. 

fixed  idea  may  be  removed  and  a  delusion  dispelled.  Under  ordinary 
circumstances  the  number  of  susceptibles  is  so  small  that  its  general 
use  is  impossible.  In  hysteria,  as  elsewhere,  it  is  a  two-edged  weapon, 
and  the  patient  may  emerge  from  hypnosis  instituted  for  a  minor  diffi- 
culty and  go  into  severe  hysterical  convulsions.  One  delusion  may  be 
removed,  but  another  and  more  serious  one  of  mind-reading  or  undue 
influence  may  be  implanted.  For  obvious  reasons,  women  should  never 
be  hypnotized  without  reliable  witnesses,  and  the  public  use  of  hypno- 
tism can  only  appeal  to  the  morbid.  In  this  connection  its  power  for 
harm  is  proven.  There  is  no  longer  any  doubt  that  its  frequent  repe- 
tition is  harmful  to  the  individual.  It  tends  to  destroy  self-reliance 
and  to  make  patients  imaginative,  weak-minded,  and  neurasthenic.  It 
also  has  a  tendency  to  bring  discredit  upon  its  employer,  and  in  most 
instances  would  better  be  substituted  by  measures  of  equal  efficiency 
and  less  disadvantage.  Suggestion,  however,  is  a  mighty  aid  to  the 
physician,  and,  without  producing  hypnosis,  positive  and  intelligent 
assertion  can  accomplish  all  that  is  likely  to  be  done  by  hypnotism 
short  of  the  somnambulistic  stage.  A  fair  realization  of  the  part  sug- 
gestion plays  in  therapeutics  is  one  of  the  recent  achievements  of  the 
most  progressive  medical  minds. 


MENTAL  DISEASES. 


BY 


FREDERICK  PETERSON,  M.  D., 

PRESIDENT  OF  THE  NEW   YORK  STATE  COMMISSION   IN   LUNACY  ;  CHIEF  OF  CLINIC, 
DEPARTMENT  FOR  NERVOUS  DISEASES,    COLUMBIA   UNIVERSITY  ;    INSTRUC- 
TOR  IN  MENTAL   DISEASES,    COLUMBIA   UNIVERSITY;  GENERAL 
CONSULTANT  TO  THE  CRAIG  COLONY  FOR   EPILEPTICS, 
AT  SONYEA,    NEW  YORK. 


41 


MENTAL  DISEASES. 


CHAPTER    I. 
INSANITY. 

Synonyms. — Psychosis,  Psychopathy.      German :  Irrsinn,  Irresein,  Yerrucktheit, 
Wahnsinn.     French :  Ahenation  mentale,  Fohe. 

It  is  the  object  of  the  author  to  bring  together  in  the  following 
chapters  such  matter  in  relation  to  the  definition,  classification,  etiology, 
pathology,  symptomatology,  and  treatment  of  insanity  as  will  be  of 
actual  practical  value  to  the  medical  student  and  general  practitioner. 

The  seeker  after  special  information  and  deeper  knowledge  of  the 
complex  subject  of  morbid  psychology  must  be  referred  to  the  many 
profound  works  which  deal  with  this  exclusively.  These  chapters  are 
based  upon  my  clinical  lectures  given  at  the  Manhattan  State  Hospital 
for  the  Insane  and  at  the  Randall's  Island  Asylum  for  Idiots  during 
the  past  four  or  five  years,  to  the  students  of  the  College  of  Physicians 
and  Surgeons  of  Columbia  University,  and  to  the  students  of  the 
Woman's  Medical  College  of  the  New  York  Infirmary.  They,  there- 
fore, embody  only  the  facts  which  I  believe  to  be  the  most  serviceable 
and  useful  to  those  who  are  often  practically  concerned  with  the  early 
diagnosis  and  prognosis  of  insanity,  and  who  must  be  the  first  arbiters 
as  to  the  course  of  care  and  treatment  to  be  pursued. 

Definition. — The  difficulty  of  making  a  rigid  definition  of  insanity 
is  recognized  by  all  who  have  attempted  it.  So  various  are  the  mani- 
festations of  mental  aberration,  so  many  the  faculties  involved,  so  differ- 
ent the  degrees  of  deviation  from  the  normal,  it  is  no  wonder  that  the 
expert  hesitates  and  often  fails  in  the  effort.  The  definition,  too,  must 
include  idiocy,  and  must  exclude  certain  states  of  transitory  mental  dis- 
order, such  as  the  delirium  of  fevers  and  of  intoxications. 

The  noted  English  jurist,  Lord  Justice  Blackburn,  once  said,  while' 
giving  evidence  before  a  committee  of  the  House  of  Commons:  "I 
have  read  every  definition  which  I  could  meet  with,  and  never  was 
satisfied  with  one  of  them,  and  have  endeavored  in  vain  to  make  one 
satisfactory  to  myself  I  verily  believe  that  it  is  not  in  human  power 
to  do  it." 

Fortunately,  we  are  not  often  called  upon  to  give  a  definition  of 
insanity,  and   usually  we  may  reply  that  insanity  is  a  symptom  of  so 

643 


644  MENTAL   DISEASES. 

many  obscure  pathological  states,  and  appears  in  such  clivers  forms  that 
a  narrow  definition  is  not  possible.  However,  the  practitioner  may 
find  himself  in  the  \\itness-box  some  day,  and  it  is  not  uncommon  for 
one  of  the  legal  examiners  to  ask  of  the  witness  in  a  mental  case  a  defi- 
nition of  insanity.  If  the  witness  be  wise,  he  will  answer  as  indicated, 
or  he  may  qualify  such  answer  by  oifering  to  quote  some  one  of  the 
definitions  given  by  alienists,  such  as  follow  : 

A  disease  of  the  brain  (idiopathic  or  sympathetic)  affecting  the  in- 
tegrity of  the  mind,  whether  marked  by  intellectual  or  emotional  dis- 
order.— (Hack  Tuke.) 

A  special  disease,  a  form  of  alienation  characterized  by  the  acci- 
dental, unconscious,  and  more  or  less  permanent  disturbance  of  the 
reason. — (Regis.) 

Morbid  derangement,  generally  chronic,  of  the  supreme  cerebral 
centers, — the  gray  matter  of  the  cerebral  convolutions  or  the  inteUecto- 
rium  commune, — giving  rise  to  perverted  feeling,  defective  or  erroneous 
ideation,  and  discordant  conduct,  conjointly  or  separately,  and  more 
or  less  incapacitating  the  individual  for  his  due  social  relations. — 
(Maudsley.) 

Insanity  is  either  the  inability  of  the  individual  to  correctly  register 
and  reproduce  impressions  (and  conceptions  based  on  these)  in  sufficient 
number  and  intensity  to  serve  as  guides  to  actions  in  harmony  with  the 
individual's  age,  circumstances,  and  surroundings,  and  to  limit  himself 
to  the  registration  as  subjective  realities  of  impression  transmitted  by 
the  peripheral  organs  of  sensation,  or  the  failure  to  projDerly  co5rdi- 
nate  such  impressions  and  to  thereon  frame  logical  conclusions  and 
actions,  these  abilities  and  failures  being  in  every  instance  considered 
as  excluding  the  ordinary  influences  of  sleep,  trance,  somnambulism ; 
the  common  manifestations  of  the  general  neuroses,  such  as  epilepsy, 
hysteria,  and  chorea ;  of  febrile  delirium,  coma,  acute  intoxications, 
intense  mental  preoccupation ;  and  the  ordinary  immediate  effects  of 
nervous  shock  and  injury. — (Spitzka.) 

With  these  few  examples  before  us  of  the  diversity  of  definition 
attained  by  careful  students  of  psychiatry,  we  may  well  content  our- 
selves and  acknowledge  that  a  satisfactory  definition  in  brief  form  is 
scarcely  to  be  devised.  The  writer  has  often  qualified  this  by  offering 
the  following,  which  has  at  least  the  merit  of  brevity,  if  not  of  perfect 
adequacy  : 

Lisanity  is  a  manifestation  in  language  or  conduct  of  disease  or  defect 
of  the  brain. 

The  law  a.ssumes  to  offer  certain  definitions  of  insanity,  from  which, 
however,  those  of  medicine  would  tend  to  differ,  in  connection  with  the 
three  chief  points  where  law  and  psychiatric  medicine  meet : 

1.  A  criminal  is  insane  if  he  does  an  act  whose  nature  and  quality 
he  does  not  know,  or  if,  knowing  the  nature  and  quality  of  his  act,  he 
does  not  know  whether  it  is  right  or  wrong. 

2.  A  testator  is  insane  if  his  mind,  memory,  or  understanding  is 
unsound. 

3.  In  a  lunacy  inquisition  the  subject  of  the  inquiry  is  insane  if  he 


INSANITY.  645 

is  incapable  of  managing  himself  and  his  affairs.     Such  are  the  diver- 
gent tests  of  insanity  in  law. 

Classification. — What  has  been  said  of  the  difficulty  of  defining 
insanity  is  equally  applicable  to  classification.  Not  all  of  the  writers- 
of  works  on  psychiatry  have  deemed  it  expedient  to  offer  a  definition 
of  insanity,  but  there  is  scarcely  one  who  has  not  ])resented  us  with  an 
original  classification,  or  one  modeled  upon,  or  modified  from,  that  of 
his  favorite  authority.  It  will  be  impossible  as  well  as  useless  to 
attempt  to  enumerate  in  these  pages  one-half  of  the  many  classifications 
which  have  been  made,  held  for  a  time,  and  finally  abandoned  with  the. 
advance  of  science  and  the  accumulation  of  new  facts  in  the  domains; 
of  pathology  and  psychology.  It  suffices  to  say  that  there  are  at  least 
forty  such  classifications  which  have  been  made  upon  etiological,  psy- 
chological, symptomatological,  or  pathological  grounds.  I  shall  present 
here,  simply  as  examples  for  reference,  several  of  the  latest  and  best 
classifications  of  the  Anglo-American,  German,  and  French  schools. 

The  Statistical  Committee  of  the  Medico-psychological  Association 
of  Great  Britain  adopted  the  following  classification  for  use  by  the 
medical  superintendents  of  asylums  : 

1.  Congenital  or  infantile  mental  deficiency — 

a.  With  epilepsy. 
h.  Without  epilepsy. 

2.  Epilepsy  (acquired). 

3.  General  paralysis  of  the  insane. 

4.  Mania — recent,  chronic,  recurrent,  a  potu,  puerperal,  senile. 

5.  Melancholia — recent,  chronic,  recurrent,  puerperal,  senile. 

6.  Dementia — primary,  secondary,  senile,  organic,  — *'.  e. ,  from  tumors,  coarse  brain 

disease. 

7.  Delusional  insanity. 

8.  Moral  insanity. 

Maudsley's  grouping  is  as  follows  : 

I.  Affective  or  Pathetic  Insanity. 

1.  Maniacal  perversion  of  the  affective  life  (mania  without  delusion). 

2.  Melancholic  depression  without  delusion  (simple  melancholia). 

3.  Moral  alienation  proper  approaching  this,  but  not  reaching  the  degree 

of  positive  insanity  in  the  insane  temperament. 

II.  Ideational  Insanity. 

1.  General. 

a.  Mania. 

f  acute. 

b.  Mela,ncholia  < 

I  chronic. 

2.  Partial. 

a.  Monomania. 

b.  Melancholia. 

r  primary. 

3.  Dementia  i 

( secondary. 

4.  General  paralysis. 

5.  Imbecility. 


646 


3IENTAL  DISEASES. 


Classification  of  the  Congress  of  Paris  (1889)  : 

1.  Mania  (acute  delirium). 

2.  Melancholia. 

3.  Periodical  insanity  (circular  insanity,  etc. ). 

4.  Progressive  systematized  insanity. 

5.  Vesanic  dementia. 

6.  Organic  dementia. 

7.  Paralytic  insanity. 

8.  Neurotic  insanity  (hypocliondria,  hysteria,  epilepsy,  etc.), 

9.  Toxic  insanity. 

10.  Moral  and  impulsive  insanity. 

11.  Idiocy. 

The  following  is  the  classification  of  E,§gis  : 


I.  Functional  Insanity. 


Grenerahzed 


symptomatic. 


1.  Mania. 


2.  Melan- 
cholia. 


Subacute  mania  (maniacal  excitation). 
Acuta  mania  (typical  mania). 
Hyperacute  mania  (acute  delirium). 
Chronic  mania. 
Remittent  or  intermittent  mania. 

Subacute  melancholia  (melancholic  depres- 
sion). 
Acute  melancholia  (typical  melancholia). 
Hyperacute  melancholia  (with  stupor). 
Chronic  melancholia. 
Remittent  or  intermittent  melancholia. 


Partial  or 
essential  insanity. 


{continuous, 
intermittent. 

Systematized  (  fl^l^f^^  (hypochondriacal  insanity) 
nrnffrpssivp.     /  i 


progressive 
insanity, 


stage  (persecutory,  religious,  erotic, 
political,  etc.). 
Third  stage  (ambitious  insanity). 


II.  Constitutional  Insanity. 

Disharmony  (defect  of  equilibrium,  irregularity,  eccentricity). 
Neurasthenia  (fixed  ideas,  impulsions,  aboulias). 


Degeneracy  of 
evolution. 
(Vices  of  or- 
ganization. ) 

Degeneracy  of  in- 
volution. 
(Disorganization . ) 


r  delusional. 
Phrenasthenias  \  reasoning. 

( instinctive. 
Monstrosities  (imbecihty,  idiocy,  cretinism,  myxedema). 

Dementia  (simple  dementia). 


Krafft-Ebing  has  drawn  up  this  scheme  : 


A.  MENTAL  DISORDERS  OF  THE  DEVELOPED  BRAEN, 
I,  PSYCHONEUROSES. 

f  simplex. 

Melancholia  \ 

[  attonita. 
1.  Primary  curable  conditions.      )    Mor.io     j  Maniacal  exaltation. 

/    Mama.    |  ^cute  mania. 
Stupor,  or  curable  dementia. 
Wahnsinn  (vesania). 


INSANITY.  647 

!    Secondary  monomania  (Verriicktlieit). 
[  agitated. 
Terminal  dementia  \ 
[  apathetic. 
II.  Psychic  Degeneracies. 

1.  Reasoning  insanity. 

2.  Moral  insanity. 

3.  Primary  monomania  (primare  Verriicktheit — persecutory,    erotic,  reli- 

gious, ambitious). 

4.  With  imperative  conceptions. 

[epileptic. 

5.  Insanity  from  constitutional  neuroses  \  hysterical. 

( hypochondriacal. 

6.  Periodical. 

III.  Cerebral  Diseases  with  Marked  Mental  Symptoms. 

1.  Paralytic  dementia. 

2.  Cerebral  syphilis. 

3.  Chronic  alcoholism. 

4.  Senile  dementia. 

5.  Acute  delirium. 

B.   ARRESTED  CEREBRAL  DEVELOPMENT. 

L  Idiocy.  ^ 

2.  Cretinism. 

Ziehen  has  given  the  mcst  recent,  and  in  many  respects  the  best, 
classification  of  this  decad  : 

I.  Psychoses  without  Intellectual  Defect. 

A.  Simple  psychoses. 

{Mania. 
Melancholia. 
Neurasthenia. 

Stupidity. 

!  simple, 
hallucinatory, 
ideational  (ideenfltichtige). 
stuporous, 
incoherent. 
Imperative  conceptions. 

B.  Mingled  psychoses. 

II.  Psychoses  with  Intellectual  Defect. 

a.  Congenital  weakness  (idiocy,  imbecility,  feeble-mindedness). 

b.  Acquired  weakness,  or  dementia. 

L  Paralytic  dementia. 

2.  Senile  dementia. 

3.  Secondary  dementia  (after  functional  psychoses). 

4.  Secondary  dementia  (after  cerebral  lesions,  syphilis,  etc.). 

5.  Epileptic  dementia. 

6.  Alcoholic  dementia. 

To  any  but  the  expert  and  special  student  some  of  these  classifica- 
tions must,  indeed,  be  mystifying  and  incomprehensible.  They  are  for- 
bidding to  the  ordinary  student  and  to  the  general  practitioner,  and 
might  well  induce  him  to  shun  the  realms  of  f)sychiatry  which  open 


648  3IENTAL  DISEASES. 

before  him  so  uninvitingly  and  present  such  obstacles  to  his  progress. 
And  the  fact  is  that  they  are  interesting  to  the  specialist  alone  because 
they  are  as  vet  quite  impracticable  from  the  standpoint  of  actual 
utility,  as  is  evidenced  by  the  employment  even  by  the  physicians  of 
asylums,  who  are  nothing  if  not  practical  alienists,  of  far  simpler 
schemes  of  classification  in  the  preparation  of  statistics  for  their  annual 
reports  and  in  the  histories  entered  upon  their  ease-books.  If  the  asy- 
lum practitioners  are  compelled  for  practical  purposes  to  adopt  a  simple 
method  of  classification,  how  is  the  novitiate  in  psychiatric  learning  to 
surpass  them  in  the  diagnosis  and  grouping  of  his  cases?  Here,  for 
instance,  is  the  latest  classification  for  statistical  purposes  made  for  the 
asvlums  of  New  York  State  by  the  State  Commission  in  Lunacy 
(1897)  : 

Mania,  acute  delirious. 
Mania,  acute. 
Mania,  recurrent. 
Mania,  chronic. 
Melancholia,  acute. 
Melancholia,  simple. 
Melancholia,  chronic. 
Alternating  (circular)  insanity. 
Paranoia. 
General  paralysis. 
Dementia,  primary. 
Dementia,  terminal. 
EpHepsy  with  insanity. 
Idiocy. 

With  this  direct  evidence  of  the  practical  necessity  of  a  simple 
grouping  of  cases  into  forms  of  insanity  which  are  readily  distinguished 
from  one  another,  I  have  felt  that  I  could  not  do  better  in  my  teaching 
than  to  adopt  some  similar  arrangement.  It  took  me  a  long  time,  after 
beginning  a  residence  of  several  years  in  a  large  insane  asylum,  to 
crystallize  the  types,  which  were  at  first  very  confusing,  into  some  sort 
of  systematic  division.  The  student  or  practitioner  unfamiliar  with 
insanity  would,  upon  a  visit  to  a  large  institution,  probably  be  first 
struck  by  the  peculiar  shapes  of  heads  of  some  of  the  patients.  He 
would  find,  upon  inquiry,  that  the  cases  Avith  malformed  crania  were 
congenital  idiots,  imbeciles,  or  feeble-minded,  and  before  much  time  had 
elapsed  he  would  unconsciously  make  in  his  own  mind  the  two  great 
divisions  of  the  insane  into  those  with  diseased  brains  and  those  with 
defective  brains.  The  former  class  includes  the  brains  which  had  devel- 
oped normally  for  years  and  had  then  fallen  a  prey  to  disease ;  the 
latter  the  brains  affected  by  congenital  defect  or  by  defect  acquired 
through  organic  diseases  in  earliest  childhood.  In  other  words,  he 
would  separate  them  first  into  the  insane  proper  and  idiots.  The  term 
idiocy  comprises  three  degrees  of  mental  impairment^ — profound  idiocy, 
moderate  defect  or  imbecility,  and  mere  weakness  of  mind,  or  feeble- 
mindedness. 

Now,  as  the  student  proceeds  to  study  the  physiognomy,  conduct, 
and  speech  of  the  cases  of  insanity  proper,  he  distinguishes,  ere  long, 
states  of  depression  (the  gloomy  visages  and   unhappy  ideas  of  melan- 


INSANITY.  649 

cholia)  and  states  of  exaltation  (the  ideomotor  excitement  of  mania). 
Their  histories  will  tell  him  whether  they  are  acute,  subacute,  chronic, 
or  recurrent,  and  whether  they  are  puerperal,  lactational,  climacteric, 
senile,  epileptic,  hysterical,  toxic,  etc.,  in  their  origin.  A  very  small 
percentage  of  cases  presents  the  curious  ph(Miomena  of  alternating 
phases  of  mania,  lucid  intervals,  and  melanciiolia,  giving  the  entity  a 
cyclical  character,  and  these  rare  examples  of  mental  disorder  are  dis- 
tinguished as  circular  insanity. 

Epilepsy  is  found  in  a  considerable  proportion  of  the  inmates  of 
asylums, — sometimes  conjoined  with  idiocy,  sometimes  with  dementia, 
sometimes  with  symptoms  of  mania  or  melanciiolia,  and  often  present- 
ing peculiar  qualities  of  mental  disorder  which  render  the  subject  of 
epileptic  insanity  worthy  of  a  separate  chapter.  A  very  large  group  of 
patients  in  the  asylum  would  probably  impress  him  as  being  idiotic  or 
imbecile  by  their  speech  and  demeanor,  and  yet  he  would  observe  them 
to  have  normally  shaped  heads,  and  traces  of  old  intelligence  might  be 
manifest.  By  inquiry  into  the  histories  of  these  numerous  patients  he 
would  tind  that  the  mental  enfeeblement  so  plainly  apparent  had  been  a 
sequel  to  a  serious  antecedent  brain-storm,  had  followed  upon  *ui  attack 
of  mania  or  melancholia,  and  that  the  designation  of  this  condition  is 
accordingly  secondary  or  terminal  dementia.  The  term  "  dementia  "  means 
in  psychiatry  enfeeblement  of  the  mind.  There  are  rare  cases  where 
such  enfeeblement  develops  ab  initio — e.  g.,  without  either  of  the  ante- 
cedent psychoses  just  described,  and  this  condition  is  entitled  primary 
dementia. 

Still  another  considerable  group  of  cases  becomes  distinct  upon  fur- 
ther study,  a  syndrome  identified  by  progressive  mental  enfeeblement, 
accompanied  by  progressively  increasing  paresis  or  paralysis  of  the 
muscles  of  speech,  of  the  face,  of  deglutition,  of  the  limbs,  in  fact  of 
the  whole  body, — dementia  paralytica,  general  paresis,  or  general  paraly- 
sis of  the  insane, — with  its  phases  of  grandiose  ideas,  tremor,  epilepti- 
form and  apoplectiform  episodes,  exaggerated  or  lost  knee-jerks,  and 
Argyll  Robertson  pupils. 

He  would  then  begin  to  be  puzzled  by  the  fixed  delusions  of  perse- 
cution and  grandeur,  especially  by  the  former,  which  he  would  encounter 
in  many  patients, — in  some  rather  confused,  weak,  and  transitory  ;  in 
others  systematized  into  a  most  elaborate  scheme,  with  considerable  logic 
and  intelligence.  Some  study  of  these  would  lead  the  student  to  place 
the  less  elaborate  persecutory  ideas  among  the  melancholiacs,  alcoholics, 
etc.,  the  less  elaborate  grandiose  ideas  among  the  chronic  maniacs  and 
general  paretics,  while  the  wonderfully  elaborated  delusions  of  gran- 
deur and  persecution  oi paranoia  would  lead  him  to  recognize  under  this 
heading  the  remarkable  mental  disorder  known  to  the  Germans  as 
"  primare  Verriicktheit,"  to  the  English  as  chronic  delusional  insanity, 
and  once  familiar  to  us  by  the  rather  indefinite  term  of  monomania. 

I  shall  leave  for  discussion  under  separate  headings  any  further  sub- 
divisions that  seem  to  me  useful.  The  outline  just  given  must  serve 
the  purpose  of  a  foundation  upon  which  the  student  will  rear  such 
superstructure  as  his  time  and  inclination  may  permit.     Accordingly, 


650  MENTAL   DISEASES. 

the  chapters  on  special   forms  of  insanity  in  this  book  will  be  simply 
arranged  as  follows  : 

1.  Mania. 

2.  Melancholia. 

3.  Circular  insanity. 

4.  Epileptic  insanity. 

5.  Dementia  (primary  and  secondary). 

6.  General  paresis  (paralytic  dementia). 

7.  Paranoia. 

8.  Idiocy,  imbecility,  and  feeble-mindedness. 

A  REVIEW  OF  RECENT  PROBLEMS  OF  PSYCHIATRY.  ^ 

Most  text-books  of  psychiatry  show  plainly  an  effort  at  harmonizing  one's  daily 
experience  with  that  which  one  may  consider  the  safe  scientific  generalization  of  the 
age  or  of  the  individual.  Some  writers  do  it  chiefly  for  didactic  purposes,  in  order 
to  shape  the  mental  attitude  of  students  ;  others  more  especially  because  their  ex- 
perience is  continually  fermenting  in  them,  and  demands  an  orderly  arrangement  in 
order  to  give  them  peace  and  satisfaction.  In  any  such  effort  we  may  distinguish 
those  whose  tendency  goes  more  in  the  direction  of  harmonizing  the  facts  of  experi- 
ence with  a  "  science  "  which  they  consider  established  and  having  a  set  form,  while 
others  set  the  facts  of  experience  foremost,  and  adapt  the  order  of  the  science  to 
their  needs.  The  large  number,  of  course,  of  those  who  practice  the  specialty  are 
on  free  empirical  ground — persons  who  are  more  or  less  professedly,  and_ perhaps 
with  preference,  without  system,  and  get  along  best  without  taking  a  definite  stand 
of  their  own  on  general  questions,  and  who,  if  they  be  teachers,  render  the  general 
consensus  without  any  special  interest  one  way  or  another. 

After  all,  progress  is  possible  without  any  very  broad  scientific  system.  The  first 
need  is  a  knack  of  observation  and  of  seeing  distinctions  ;  and  the  next,  to  draw  the 
necessary  inferences,  to  see  their  most  suggestive  sides,  and  to  use  this  material 
properly.  We  see,  however,  that  discoveries  of  the  unsystematic  are  easily  used  for 
sweeping  generalizations,  which  are  proved  or  disproved  only  in  the  course  of  time, 
as  general  theories  and  especially  many  so-called  discoveries  in  therapeutics  show. 
The  more  the  discoverer  has  a  systematized  and  scrutinized  stock  of  facts  and  a  keen 
eye  for  illusions  of  perception  and  of  reasoning,  the  more  is  he  likely  to  put  forth  his 
findings  in  a  sound  permanent  hght. 

In  the  history  of  scientific  progress  undoubtedly  those  with  a  need  of  setting 
things  in  harmony  with  the  safe  data  have  been  the  chief  promoters,  and  in  order  to 
get  an  idea  of  the  most  modern  phase  of  our  specialty  we  propose  to  analyze  the 
work  of  a  few  of  these  pathfinders  for  the  purpose  of  seeing  before  us  the  plan  of 
some  lines  of  work  which  have  shaped  the  general  trend  of  interest,  and  which,  as 
the  (rermans  say,  made  schools,  i.  e. ,  were  the  start  for  whole  sets  of  new  investiga- 
tions along  the  newly  opened  paths.  Very  striking  generally  acknowledged  trans- 
formations in  this  young  specialty  of  medical  science  are  not  so  abundant  that  they 
may  not  be  reviewed  with  some  ease  at  this  date. 

In  neurology  and  psycho-pathology  nothing  has  created  so  profound  a  commotion 
as  the  discoveries  connected  with  the  study  of  aphasia,  which  were  closely  followed 
by  that  of  the  other  facts  of  cerebral  localization.  The  most  fundamental  discovery, 
from  the  alienist's  point  of  view,  is  undoubtedly  that  of  Wernicke,  in  his  demon- 
stration of  sensory  aphasia.  The  earlier  discovery  of  motor  aphasia  had  not  really 
pointed  so  forcibly  to  the  need  of  an  inner  analysis  of  the  processes  of  speech  and 
thought,  being  too  largely  like  the  loss  of  a  tool,  and  not  an  intrinsic  disorder.  'In 
line  with  the  discovery  of  sensory  aphasia,  we  note,  also  from  Wernicke's  school,  the 
great  development  of  our  knowledge  of  mind-blindness,  and  of  apraxia. 

In  psychiatry  proper  we  see  a  large  amount  of  valuable  work  grouped  around  the 
problem  of  etiology.  The  mere  psychological  description  of  types  of  mental  de- 
rangement being  so  very  complex, — apparently  an  almost  endless  task  with  endless 
disappointment  and  disagreement, — -the  problem  of  heredity  attracted  the  attention 

^  This  review,  particularly  of  the  work  of  Kraepelin,  Ziehen,  and  Wernicke,  has 
been  prepared  by  Dr.  Adolf  Meyer,  Director  of  the  Pathological  Institute  of  the  New 
York  State  Hospitals. 


A  REVIEW  OF  RECENT  PROBLEJIS  OF  PSYCHIATRY.  651 

of  all  through  the  work  of  Morel  and  his  followers.  It  has  established  facts  which 
are,  however,  in  much  need  of  explanation  themselves,  and  not  very  productive  of 
further  knowledge.  Their  i)resent  influence  is  largely  in  pointing  to  the  necessity 
of  a  future  stutly  of  constitution,  and  to  caution  in  questions  of  etiology  generally, 
inasmucli  as  they  show  the  need  of  considering  a  special  predisposition  besides  the 
exciting  causes.  For  the  most  important  result  to  be  expected  from  it  in  the  future, 
the  question  who  is  entitled  to  progeny,  the  facts  as  well  as  human  society  are  far 
from  being  mature. 

A  very  stirring  turn  in  psyehiatrj'  has  come  lately  from  Kraepelin.  who  took  a 
stand  foreshadowed  by  Kahlbaum,  but  never  demonstrated  with  such  consistencj' 
before.  With  the  fifth  edition  of  his  text-book,  the  time  had  come  to  break  away 
from  the  resigned  symptomatic  attitude.  The  pride  of  the  clinician  demanded 
disease-entities,  and  conditions  seemed  mature  enough  to  claim  at  least  a  large 
number  of  the  types  and  the  cases  for  definite  pathological  or  at  least  nosological 
entities.  This  was  achieved  by  the  consideration  of  the  evolution  of  the  whole  life 
in  insane  patients,  and  utilization  of  a  retrosijective  review  of  the  development  in 
such  as  had  reached  terminal  stages.  Kraepelin  was  encouraged  by  such  a  review, 
owing  to  the  similarity  of  the  outcome  of  the  disease,  to  form  groups  of  cases  which 
had  been  regarded  as  distinct  before,  because  they  represent  what  seem  to  be  dis- 
tinct symptom-complexes.  To  start  with,  Kraepelin  showed  that  they  might  be 
diagnosed  to  better  advantage  and  with  a  prognostic  forecast  from  the  very  start  if 
certain  facts  were  taken  into  account.  His  emphasis  of  the  nature  of  course  and 
OMteome  for  the  shaping  of  "disease-entities"  has  certainly  freshened  interest  in 
observation  remarkably.  He  was  in  part  pushed  to  this  attitude  by  the  extreme 
stand  of  a  former  assistant  of  Kahlbaum  (Ziehen),  who  subsequently  developed  a 
psychology  and  psychiatry  on  the  basis  of  a  modernized  Herbartianism,  and  associa- 
tion-psychology. A  review  of  Ziehen's  psychiatry  by  Kraepelin  brings  the  contrast 
between  psychological  and  clinical  psychiatry  to  a  culmination,  and  the  fifth  edition 
of  the  text-book  Vas  the  book  Kraepelin  promised  in  his  review  of  Ziehen's  work 
("Zeitschrift  fiir  Nervenheilkunde,"  1894). 

While  these  two  extremes  developed,  Wernicke  had  gradually  published  his 
"Psychiatry,"  which  stands  now  before  us  as  the  most  recent  fundamental  work, 
and  which  deserves  very  careful  analysis  by  every  one  who  is  interested  in  the  de- 
velopment of  psychiatric  thought,  owing  to  its  clinical  accuracy  and  the  efforts  at 
explaining  mental  diseases  as  disorders  of  ftinction  of  the  nervous  system . 

This  provisional  summary  is,  of  course,  not  a  complete  picture  of  what  I  consider 
valuable  psychiatric  literature.  There  are  many  excellent  works  of  a  less  extreme 
attitude  which  probably  depict  much  more  satisfactorily  the  current  standing  of  the 
specialty,  but  which  are  more  didactic  and  not  likely  to  inspire  to  research.  Most 
of  the  English  and  American  text -books  belong  in  this  category  ;  also  many  of  the 
French  and  Italian  works,  and  in  Grerman  literature  especially  Schiile,  KrafiFt-Ebing, 
and  Sommer,  who  depicts  the  modern  trend. 

Before  entering  into  the  details,  we  wish  to  give  the  reader  a  brief  characteriza- 
tion of  the  tendencies  which  we  propose  to  analyze.  This  may  lead  to  preconceived 
ideas ;  but  any  harm  will,  we  hope,  be  corrected  by  the  expected  effect  of  the  _  re- 
view, that  the  reader  will  feel  sufficiently  interested  to  go  himself  to  the  original 
works,  and  a  preliminary  outline  will  bring  out  the  issues  more  rapidly  and  clearly. 

The  average  work  on  mental  disease  cannot  quite  escape  the  comment  that  it  is 
an  attempt  to  give  a  list  of  accepted  traditional  terms  of  mental  disease  some  justi- 
fication, in  the  face  of  an  obviously  much  larger  variety  of  cases  than  these  terms 
and  standard  descriptions  can  cover.  The  result  is  rather  unsatisfactory.  I  am, 
therefore,  not  surprised  that  most  of  the  alienists  with  whom  I  come  in  contact  con- 
sider it  hardly  worth  their  while  to  keep  track  of  the  interpretations  given  by  more 
than  a  few  text-books  which  they  take  as  standards. 

The  types  of  "  psychiatries  "  which  we  are  about  to  discuss  are  not  quite  free  of 
this  charge,  since  in  order  to  he  understood  at  all,  one  must  use  the  language  and 
the  terminology  as  it  is,  and  trust  that  the  reader  will  respect  one's  definitions,  and 
not  give  the  names  and  words  an  arbitrary  meaning.  These  definitions  must  start 
from  views  which  one  has  a  right  to  consider  as  held  in  common,  and  any  attempt 
at  inventing  too  many  new  names  meets  a  prompt  revenge,  as  the  fate  of  the  books 
of  Kahlbaum  and  Arndt  have  shown.  But  we  can  claim,  for  all  the  writers  dis- 
cussed here,  a  conscientious  effort  to  start  in  the  first  place  fr'om  sets  of  patients,  and 
to  adapt  their  descriptions  and  tei-ms  to  what  they  see.  without  any  unnecessary 
regard  for  traditional  classification  of  words. 


652  MENTAL  DISEASES. 

This  is  perhaps  least  obvious  with  Ziehen.  With  him,  the  system  of  available 
terminology  is  responsible  for  his  divisions  to  a  great  extent.  In  his  general  path- 
ology the  system  of  his  association-psychology  also  furnishes  the  backbone  for 
pathological  psychology.  Given  the  headings  of  the  chapter  in  normal  psychology, 
one  can  construct  with  ease  the  subheads  of  the  chapter  on  pathology. 

This  form  is  naturally  dry,  and  does  not  quite  do  justice  to  the  readability  of 
the  very  good  observations  of  fact  which  are  classified  in  this  very  systematic  man- 
ner. The  student  may  be  grateful  for  the  beautiful  order  ;  but  the  practitioner  does 
not  see  the  things  as  the  teacher  puts  them  down.  What  is  to  him  an  entity  of 
great  precision  and  value  is  torn  apart  here,  and  he  naturally  asks.  To  what  advant- 
age ?  The  beautiful  order  does  not  dispel  his  fear  that  over  the  details  he  might 
fail  to  see  the  otherwise  familiar  and  practically  useful  entity. 

When  we  come  to  the  division  on  special  psychiatry,  the  description  of  the 
actual  disease-types,  the  psychological  order  is  again  uppermost,  as  we  shall  see  later 
in  our  analysis. 

Kraepelin  is  diametrically  opposed  to  this  in  his  latest  editions.  It  is  true  that 
he,  too,  sought  his  salvation  in  psychology,  and  classifies  the  facts  in  his  general 
pathology  somewhat  according  to  the  headings  of  Wundt's  psychology.  In  the 
former  editions  he  had  but  few  headings  of  special  disease-types,  mostly  in  harmony 
with  the  accepted  terminology  built  on  a  few  standard  types  of  disorders  which  are 
supposed  to  be  open  to  psychological  classification.  Of  these,  I  mention  the  stand- 
ards :  States  of  depression  (simple  melancholia  and  melancholia  with  delusions); 
states  of  mental  obscuration  (hypnotism,  somnambulism,  epileptic  and  hysterical 
states;  stupor  and  ecstasis,  and  acute  dementia);  states  of  excitement  (melancholia 
activa,  mania,  delirium);  periodic  psychoses  (mania,  melancholia,  circular  forms); 
paranoia;  paralytic  dementia  ;  states  of  psychic  defect. 

In  the  fifth  edition  Kraepelin  breaks  loose  from  the  satisfaction  with  this  symp- 
tomatic compromise  and  proclaims  the  need  of  broader  nosological  principles  ;  medi- 
cal interests,  not  a  psychological  system,  shall  decide  the  classification  ;  the  medical 
questions  of  course,  prognosis,  and  outcome  demand  the  first  place :  and  among 
these  the  prognosis  is  the  most  important.  He  divides  most  of  the  so-called  acute 
disorders  into  recoverable  forms  and  psychoses  of  deterioration,  and  makes  this  divi- 
sion an  important  principle  of  classification.  Superficially  very  heterogeneous  symp- 
tom-complexes are  thus  brought  under  one  head,  and  broader,  not  necessarily  psy- 
chological or  etiological,  facts  are  the  new  guides. 

Wernicke  is  very  decided  in  his  antagonism  to  Kraepelin' s  sweeping  innovation. 
He  considers  such  an  undertaking  premature.  Probably  this  is  an  extreme  view. 
But  he  has  a  great  point  in  his  favor,  that  of  frank  admission  that  a  complete  com- 
prehension of  all  the  psychoses  is  not  to  be  expected  to-day,  that  certain  groups  of 
cases,  however,  can  be  sufl&ciently  understood  and  harmonized  with  our  knowledge 
of  neurological  and  psychological  facts.  On  the  other  hand,  he  condemns  all  at- 
tempts to  obscure  the  line  of  distinction  between  what  is  clinically  known  and  what 
is  not  known,  even  if  this  be  done  under  the  appearance  of  leading  to  broader  con- 
cepts._  We  shall  see  that  he  himself  does  not  use  the  same  reserve  in  his  own 
theories  of  localization. 

_A  very  concise  and  clear  statement  of  Wernicke's  position  is  contained  in  his 
article  on  the  classification  of  psychoses.  ^ 

He  makes  due  reference  to  his  predecessor,  H.  Neumann,  who  recognized  only 
one  "  insanity,"  or  as  many  mental  disorders  as  there  are  diseased  persons,  in  con- 
trast to  the  dogmatic  Griesinger,  who  built  a  psychiatry  on  psychological  ideas  with 
observations  borrowed  from  the  literature.  Neumann  was  one  of  the  founders  of  a 
conscientious  symptomatology.  He  made  a  deep  impression  on  Kahlbaum,  whose 
work  Wernicke  considers  the  most  valuable  to  this  day,  ^  although  it  is  evidently 
encumbered  by  haziness  owing  to  his  desire  to  do  justice  to  Neumann  (especially  -the 
idea  that  all  typical  insanity  shows  four  stages  :  melancholia,  mania,  confusion,  and 
dementia)._  Kahlbaum 's  great  merit  is  the  distinction  between  Habitualbild  (or 
Zustandsbild),  ^.  e. ,  the  temporary  symptom-complex,  and  the  actual  underlying 
disease  ;  and  the  recognition  that  most  of  the  so-called  forms  of  insanity  are  merely 
pictures  of  symptom-complexes  without  sufiicient  analysis  of  their  nosological  bear- 
ings.    Wernicke  next  mentions  Meynert,  who  adheres  to  the  current  headings  of 

^  "  Psychiatrische  Abhandlungen, "  Hef 1 12.  Breslau,  1899.  Schletter'sche  Buch- 
handlung. 

"  "  Ueber  die  Gruppirung  von  Geisteskrankheiten, "  Danzig,  1863. 


A  liEVIEW  OF  RECENT  PROBLEMS  OF  PSYCHIATRY.  653 

mania,  melancholia,  secondary  insanity,  and  dementia,  and  classifies  all  the  rest  of 
the  acute  psychoses  as  amentia.  He  finally  mentions  Kraepelin's  classification  as 
j)robably  the  most  popular,  and  elaims  that  notwithstanding  Kraepelin's  emphatic 
defense,  it  is  essentially  an  etiological  grouping. 

Wernicke  has  an  easy  task  to  show  tliat  etiology  alone  will  always  remain  insuffi- 
cient for  classification.  Acute  hallucinosis  occurs  usually  in  alcoholism,  but  also 
without  alcohol.  The  polyneuritic  psychosis  is  essentially  like  certain  senile  disorders. 
Alcoholism  may  lead  to  :  (1)  the  so-called  transitory  frenzy  or  pathological  intoxica- 
tion ;  (2)  delirium  tremens ;  (3)  polyneuritic  psychosis ;  (4)  acute  hallucinosis ; 
(5)  psychosis  with  anxiety,  so  frequent  in  alcoholics.  Unless  this  is  recognized  and 
the  forms  are  kept  clearly  distinct,  we  return  to  a  general  confusion  and  haziness. 
On  the  other  hand,  Wernicke  recognizes  the  importance  of  etiology  for  the  course 
of  the  disease,  as  is  plainly  shown  in  the  parasyphilitic  disorders  classed  as  general 
paralysis. 

Besides  etiology,  we  must  certainly  consider  the  localization  and  the  nature  of 
the  disease-process.  Even  in  as  homogeneous  an  organ  as  the  liver,  it  matters  much 
whether  a  focus  of  disease  is  involving  the  peritoneum  or  the  environment  of  the 
vena  portae  or  the  bile-duct ;  and  this  certainly  holds  much  more  strongly  for  a  com- 
plex, highly  differentiated  organ  such  as  that  of  association. 

Wernicke  applies  the  theory  of  specific  energies — according  to  which  any  stimu- 
lation of  a  nerve  is  responded  to  by  that  nerve's  specific  sensation — to  the  entire 
system  of  associations.  Every  content  of  consciousness  or  concept  depends  on  an 
altogether  definite  and  limited  set  of  nerve-elements ;  hence  his  psychiatry  turns 
primarily  to  the  disorders  of  the  contents  of  consciousness  as  the  first  factor  to 
be  considered  in  all  classification,  because  Wernicke  places  concepts  in  three 
groups  :  concepts  of  the  external  world,  of  the  body,  and  of  the  so-called  person- 
ality or  individuality  (the  sum  of  individual  memories  of  a  person).  Clinical  expe- 
rience shows,  indeed,  that  the  chronic  disorders  in  which,  according  to  Wernicke, 
the  form  and  course  of  mental  activity  are  not  disturbed  as  such,  are  apt  to  affect 
principally  one  of  the  three  fields,  either  chiefij^  the  concepts  of  the  outside  world  (in- 
cluding other  persons),  or  those  of  the  patient's  body,  or  those  of  the  patient's  per- 
sonality, and  he  therefore  divides  these  mental  disorders  into  allopsychoses,  somato- 
psychoses, and  autopsychoses,  and  the  same  principle  is  applied  to  the  acute  mental 
disorders  in  which,  besides  the  derangement  in  the  contents,  there  is  a  decided 
though  variable  affection  of  the  form  and  trend  of  mental  activity,  the  stream  of 
thought.  '^ 

Concerning  the  nature  of  the  disease-process,  Wer:.icke  is  unitarian.  Since, 
apart  from  general  paralysis,  mental  disorders  are  either  altogether  functional 
(without  an  anatomical  lesion)  or  simply  depending  on  a  primary  degenerative 
process  of  nerve-fibers  and  nene-cells,  we  have  every  reason  to  assume  that  there  is 
really  only  one  anatomical  process,  and  all  classification  will  therefore  depend  on 
etiology  and  localization  alone. 

How  does  Wernicke  analyze  his  cases  ? 

All  our  facts  of  mental  disorders  are  ])rimarily  derived  from  the  obsei-vation  of 
motor  reactions,  since  we  cannot  see  into  the  mind  directly.  We  call  them  all  disor- 
ders of  identification  (deviations  from  doing  or  thinking  or  feeling  the  rightor 
adequate  thing  in  presence  of  a  special  fact  to  be  identified),  and  we  may  distin- 
guish disorders  chiefiy  in  the  sensory  sphere  (sensory  identification),  or  disorders 
chiefly  in  the  intrapsychic  sphere  (intrapsychic  identification,  the  thinking),  or, 
finally,  disorders  mostly  involving  the  motor  mechanisms,  disorders  of  "psycho- 
motor identification."  Within  each  of  these  three  fields  we  may  expect  to  class  all 
derangements,  either  as  a  function  or  parafunction,  or  hyperfunction  (sensory,  intra- 
psychic,   or   psychomotor).     Yet  there   are   a   certain   number   of  cases  of  acute 

'  Both  Wernicke's  idea  of  concepts  and  the  division  of  conscious  phenomena  into 
content  and  form  appear  to  me  more  logical  than  biological.  The  division  of  concepts, 
according  to  Wernicke,  shoiild  point  to  certain  localizations  which  are,  however,  quite 
hypothetical  and  by  no  means  urgently  demanded  by  the  clinic,  wliich  keeps  away 
from  the  stipiilation  of  concept-centers.  Wernicke's  localization  (outside-world,  body, 
and  personality)  refers  to  topics  of  thought  and  by  no  means  to  localization  in  the 
brain.  The  division  of  mental  activity  into  form  and  content,  too,  has  also  its  draw- 
back. We  can,  even  in  chronic  p.sychoses,  see  that  disorders  of  form  might  be  made 
accountable  for  disorders  of  contents.  The  distinction  of  types  of  form,  i.  e.,  of  types 
of  the  stream  of  thought,  is  extensively  used  by  Kraepelin,  practically  with  disregard 
for  the  contents. 


654  3IENTAL  DISEASES. 

insanity  in  which  the  disorder  of  the  psychomotor  reactions  is  so  great  that  an 
analysis  of  the  psychic  content  is  really  not  possible,  and  we  must  be  satisfied  with 
the  distinction  into  akinetic,  hyperkinetic,  or  parakinetic  motility-psychoses,  until, 
after  the  disappearance  of  the  deepest  perturbation,  a  distinction  into  autopsj^chic, 
allopsychic,  and  somatopsychic  origin  becomes  possible. 

The  fundamental  assumption  of  such  a  classification  of  symptoms  is  that  all 
mental  disorders  lead  to  "  disorientation,"  a  disorder  of  "secondary  identification  " 
i.  e. ,  of  the  function  of  feeling,  thinking,  or  doing  something  or  other  in  an 
adequate  way.  Wernicke  used  the  word  in  its  broadest  way,  and  was  misunderstood 
by  a  reviewer  in  the  "American  Journal  of  Insanity,"  April,  1901  (who  also 
mistakes  Wernicke's  acute  hallucinosis  for  a  delirium  tremens,  but  otherwise  does 
him  full  justice).  Wernicke  implies  that  all  mental  disorder  shows  in  some 
inadequacy,  or  loss  of  proper  bearings,  and  this  ' '  disorientation  ' '  leads  to  a  charac- 
teristic affect,  perplexity  (easily  confused  with  melancholia,  as  often  by  those 
who  speak  of  "initial  melancholia").  He  therefore  tries  to  establish  in  acute 
psychoses  the  extent  of  autopsychic,  somatopsychic,  allopsychic,  or  diffusely  motor 
disorientation  or  lack  of  identification,  and  the  extent  of  the  accompanying  affect  of 
perplexity. 

In  explanation  we  may  give  the  following  hints.  Wernicke  distinguishes  primary 
and  secondary  identification.  The  identification  of  the  sound  of  a  word  as  a  sound 
is  the  primary,  the  grasp  on  the  meaning  is  the  mental  appreciation  or  secondary 
identification  ;  primary  identification  is  simple  sensation  ;  secondaiy  identification 
comprehends  all  the  functions  implied  in  mental  grasp  and  elaboration.  On  the  basis 
of  his  scheme  of  aphasia,  he  makes  an  anatomical  hypothesis  for  the  events  in  speech, 
in  the  form  of  a  chain  of  nervous  mechanisms,  starting  from  the  sensory  i^rojection 
field  S  (first  temporal  gyrus)  and  ending  in  the  motor  projection  field  m  (Broca's 
convolution).  The  recognition  of  a  word-sound  as  something  known  is  a  simple 
assimilation  or  primary  identification.  For  the  understanding,  the  mechanism  of 
the  concept  must  be  roused,  and  this  spreading  is  represented  by  s  C,  the  "  psy- 
chosensory path. ' '  For  the  purpose  of  adjustment  of  equilibrium  in  its  relation  to 
the  rest  of  the  person  the  concept  C  co-operates  with  a  mechanism  of  reaction  rep- 
resented by  the  concept  of  aim  or  purpose  P  ;  and  this,  again,  co-operates  with  a 
mechanism  of  enunciation  m  in  the  Broca  convolution.  The  mechanism  involved 
to  lead  from  a  simple  concept  to  the  concept  of  purpose  C  P  is  the  intrapsychic 
complex,  and  the  connection  of  the  final  concept  P  and  the  mechanism  of  enuncia- 
tion is  the  psychomotor  part  of  the  secondary  identification  or  association.  Each  of 
these  components  can  show  a  minus  or  i^lus  or  perversion  of  activity,  so  that 
Wernicke  distinguishes  : 

Psychosensory  Sphere  :  Intrapsychic  Sphere  :  Psychomotor  Sphere  : 

Anesthesia,                               Afunction,  Akinesis, 

Hyperesthesia,                         Hyperfunction,  Hyperkinesis, 

Paresthesia.                                Parafunction.  Parakinesis. 

This  correlation  of  all  psychic  function  with  the  function  of  speech  is  similar  to 
what  Stark  arrived  at  (1838),  who  recognizes  anoesis,  hypernoesis  and  paranoesis, 
and  abulia,  hyperbulia,  and  parabulia,  but  it  has  the  advantage  of  getting  along 
without  the  hazy  concepts  of  feeling,  intellect,  and  will,  by  remaining  on  a  broad 
biological  though  also  hypothetical  ground. 

Looking  back  over  this  rather  complicated  nomenclature,  one  can  hardly  suppress 
the  query  whether  the  facts  of  observation  might  not  lead  to  a  classification  of  the 
data  for  more  natural  and  less  schematic  reasons  and  with  results  which  would  be 
more  easily  manipulated  and  which  would  present  themselves  more  directly. 

Wernicke  illustrates  his  method  of  analysis  of  cases.  He  first  seeks  to  determine 
the  sphere  of  concepts  in  which  the  patient  is  disoriented  (or  we  might  say  inade- 
quate), or  at  least  threatened  with  disorientation.  Then  follows  an  analysis  of  the 
symptoms  in  accordance  with  the  scheme  of  disorders  of  identification.  Finally, 
etiologyand  course  are  considered.  Thus  delirium  tremens  is  a  psychosis  with  dis- 
orientation in  reference  to  the  outside  world,  an  allopsychosis  composed  of :  hallu- 
cinations of  the  various  sensory  domains,  especially  the  optic  and  tactile  (psychosen- 
sory hyperesthesia)  ;  illusions  (psychosensory  paresthesia);  disorientation  as  to  the 
locality  (psychosensory  anesthesia);  unrest  and  delirium  of  occupation  (psychosensory 
hyperkinesis);  at  times  anxiety  (psychosensoiy  paresthesia).  Taking  it  all  in  all,  it 
is  a  complex  of  disorders  of  psychosensory  identification,  without  independent  dis- 


A  REVIEW  OE  RECENT  PROBLEiVS  OE  PSYCHIATRY.  655 

order  of  intrapsychic  or  motor  identification  (the  patient  thinks  and  acts  correctly 
in  response  to  his  sensory  state).  There  is,  moreover,  in  addition  to  the  purely 
psychic  symptoms  and  belonging  in  the  field  of  organic  disorders,  an  afiection  of  the 
sensorium,  which  consists  in  dulness  {BenommenJieit)  to  an  extent  that  varies  at 
difterent  moments  and  is  influenced  by  external  interests  (the  patient  responds 
promptly  when  started  out  of  his  dream  state).  Furthermore,  there  are  symptoms 
fi-om  the  projection  systems  :  Tremor,  speech  disorder,  deviation  of  the  tongue, 
paresis  of  the  facial,  etc.  In  mania  and  affective  melancholia  (as  Wernicke 
describes  them),  orientation  suffers  chiefly  as  to  the  meaning  and  relation  of  the 
patient's  own  personality  (exaltation  or  ideas  of  smallness,  sin,  etc.),  and  all  the 
symptoms  are  referable  to  intrapsychic  hyperfunction  in  mania,  and  intrapsychic 
afiinction  in  affective  melancholia.  (Wernicke  includes  in  mania  simply  the  complex 
usually  called  hypomania  ;  and  under  the  term  affective  melancholia,  cases  of  simple 
depression  with  feelings  of  inefficiency,  retardation,  etc.)  This  plan  allows 
Wernicke  to  give  a  definite  symptomatic  analysis  in  about  50  per  cent,  of  the  acute 
psychoses,  whereas  the  other  half  permits  at  least  a  provisional  analysis.  Even  to 
the  most  experienced  alienist  new  combinations  are  bound  to  occur ;  but  in  every 
case  the  system  gives  opportunity  for  provisional  analysis  and  for  combination  of 
typical  traits,  which  makes  it  easy  for  any  observer  to  recognize  identical  cases  or 
distinguish  diverse  ones. 

Wernicke  enumerates  the  following  established  types:  (1)  Delirium  tremens, 
polyneuritic  psychoses,  and  presbyophrenia  are  allopsychoses  with  allopsychic  dis- 
orientation. The  acute  hallucinosis  primarily  shows  merely  allopsychic  perplexity, 
and  true  allopsychic  disorientation  only  in  the  characteristic  paranoic  phase.  It  is 
the  type  of  an  acute  hallucinatorj'  allopsychosis,  as  the  chronic  hallucinosis  is  the 
type  of  a  chronic  one.  (2)  Affective  melancholia  and  pure  mania  and  the  corre- 
sponding circular  psychoses  are  instances  of  autopsychoses ;  also  paralytic  megalo- 
mania and  primary  paranoia  ;  and  the  cases  with  dominant  ideas  (as,  for  instance, 
the  querulants)  form  a  group  of  circumscribed  autopsychoses.  (3)  Among  the  soma- 
topsychoses we  find  the  cases  of  purely  intestinal  or  more  generalized  acute  or 
chronic  pure  hypochondriacal  psychoses  (pure  inasmuch  as  the  allopsychic  orientation 
is  presei-ved,  whereas  hypochondriacal  persecutory  paranoia,  an  independent  form 
of  a  chronic  ascending  psychosis,  spreads  into  the  allopsychic  field  and  is  to  be  classi- 
fied as  allosomatopsychosis).  (4)  The  especially  frequent  cases  of  anxiety-psj^choses, 
whose  dominant  symptom  refers  them  to  the  somatopsychoses  and  makes  them  most 
closely  related  to  the  hypochondriacal  psychoses,  show  nevertheless  autopsychic  and 
allopsychic  perplexity,  and,  on  the  autopsychic  field,  also  disorientation,  so  that  they 
may  also  be  classed  with  the  combined  psychoses.  (5)  Finally,  Wernicke  mentions 
the  so-called  periodic  mania  as  a  hyperkinetic  motility  psychosis  (of  usually  men- 
strual origin),  and  the  more  or  less  pure  cases  of  akinetic  and  parakinetic  motility- 
psychoses. 

In  a  number  of  other  frequently  occurring  conditions,  as,  for  instance,  in  what 
Wernicke  calls  depressive  melancholia,  our  knowledge  is  not  sufl&ciently  definite  to 
recognize  them  as  disease-types  ;  but  the  system  makes  it  easy  to  classify  them  (with 
the  autopsychoses).  Concerning  such  uncertain  types  we  still  stand  on  the  old 
ground  of  '''"SabitiiaJformen,^'  i.  e.,  sj^mptom-complexes. 

The  idea  that  the  character  of  symptoms  changes  frequently  in  the  same  patient 
is  an  old  tradition.  According  to  Wernicke,  this  is  not  true  of  the  types  mentioned 
above,  and  when  it  does  occur  (as  sometimes  on  a  hebephrenic  basis,  and  especially  in 
general  paralysis),  the  case  is  best  classed  as  a  compound  psychosis.  There  is  cer- 
tainly far  less  regularity  in  the  sequence  than  was  formerly  held._^  The  doctrine  of 
an  initial  melancholia  has  its  origin  in  a  confusion  of  melancholia  with  the  painful 
affect  of  perplexity  which  accompanies  almost  all  the  acute  psychoses  at  their  onset 
and  even  later. 

This  free  translation  of  Wernicke's  article  gives  us  a  good  introduction  to  his 
book,  "  Grundriss  der  Psychiatric. " 

The  first  part  of  this  consists  of  a  psycho-physiological  introduction  and  elucidates 
in  great  detail  the  above  scheme  of  psychological  analysis.  Mental  diseases  are  dif- 
fuse disorders  of  the  organ  of  association,  and  can  be  dealt  with  on  the  basis  of  the 
scheme  of  aphasia.  The  adaptation  of  this  scheme  to  psychology  generally  requires 
the  recognition  of  a  distinction  between  primary  and  secondary  identification  (see 

^  As  in  Kahlhaum's  vesania  typica  and  his  definition  of  catatonia,  in  which  Neu- 
mann's cycle  of  melancholia,  mania,  confusion  dementia,  plays  such  an  unwarranted  r&le. 


6rjQ  3IEXTAL  DISEASES. 

above),  the  dissolution  of  the  '"  center  of  ideation'"  into  concepts  of  various  locali- 
zation, and  it  operates  with  originating  concepts  (C)  and  final  conceiJts  (P — final  pur- 
pose), as  the  beginning  and  end  of  the  intrapsj-chic  chain  ot  activity,  which,  of  course, 
consists  of  many  suuilar  links  (see  above  classification  of  the  scheme).  All  j^erception 
and  all  action  are  finally  presented  on  this  same  scheme.  S  is  merely  the  si^eech 
part  of  the  receptive  cortical  field,  and  m  the  speech-portion  of  the  emissive  cortical 
area.  The  trans-cortical  connections  between  the  sensory-  and  the  motor  cortex 
make  all  secondary  identification  possible.  Primary  identification  (simple  sensation) 
without  secondary  identification  (perception  and  elaboration)  would  remain  lost  and 
not  understood  in  the  optic  field  as  weU  as  in  the  sensory  speech-field.  The  third 
lecture  deals  with  the  memories,  the  fourth  with  their  association  (picture  of 
the  outside  world,  number  of  concepts,  needs  of  causative  explanations),  the  fifth 
with  the  body  and  its  .specific  sensations,  the  sixth  with  reflex  and  spontaneous 
motion,  and  its  dependence  on  sensations,  the  seventh  with  the  consciousness  of  per- 
sonality, and  the  eighth  with  the  distinction  of  content  and  activity  of  conscious- 
ness, degrees  of  con.sciousness  and  attention  and  will,  "  Merkfdhigheit''  (grasp), 
afi"ects.  and  the  equilibrium  of  ideas. 

I  do  not  feel  inclined  to  enter  into  detail  upon  Wernicke's  general  deductions,  of 
which  I  gave  an  abstract  in  the  "'Psychological  Review"  (1895).  The  eflFort  at  a 
morphological  presentation  of  mental  functions  (memory,  association,  etc.)  suffers 
from  the  same  drawbacks  as  all  correlation  of  results  of  the  working  of  a  machine 
would,  if  we  simply  tried  to  correlate  parts  of  the  result  with  parts  of  the  machine. 
Surely  the  pendulum  of  a  clock  plays  an  important  part,  but  we  can  not  identify  it 
as  such  with  the  sound ;  but  only  its  working  with  the  occurrence  of  the  sound. 

The  eighth  lecture  shows  plainly  that  the  morphological  premises  as  such,  after 
all.  are  unessential,  since  we  do  not  and  can  not  u.se  them  actually  in  the  obseiTatious 
of  the  patients.  As  soon  as  Wernicke  speaks  of  his  observations  of  patients,  the 
more  practical  issues  take  the  lead,  and  there  remain  but  a  few  assumptions  which 
Wernicke  attaches  to  his  psycho-physical  considerations,  without,  however  convinc- 
ing one  of  such  a  deep  justification  as  he  gives  the  morphological  side  of  his 
hypotheses. 

When  we  attempt  to  revie^w  the  facts  for  psychic  correlation  or  localization,  we 
do  not  get  far  beyond  what  Wernicke  calls  primary  identification.  That  pennanent 
heniianopsia  and  cortical  blindness  are  possible,  and  referable  to  destruction  of  the 
optic  radiation  and  its  cortical  field  of  projection,  is  demonstrated.  Concerning  sub- 
divisions of  the  visual  field  and  any  special  relation  of  special  localities  to  specific 
qualitative  optic  sensations  fform  and  color  and  perception  and  memory),  we  know 
nothing  conclusive.  _We  know  of  cases  in  which  vision  seems  possible  with  a  visual 
acuity  of  up  to  ^_  without  a  real  appreciation  of  what  is  seen.  In  aphasia  we  find 
numbers  and  music  reacting  in  a  special  way.  and  perhaps  they  must  be  referred  to 
special  localities  ;  but  why  the  recovery  of  words  and  diction  follows  practically  the 
sanie  laws  as  that  of  .simple  amnesia  without  organic  basis  is  not  explained  on  the 
basis  of  the  ordjnaiy  view  of  memory-cells  and  the  like.  It  is  trae  that  under  the 
title  of  mind-bhndness  Charcot  and  ^Vilbrand  have  described  peculiar  permanent 
distinctions  of  modes  of  mental  reactions.  Charcot"  s  case  of  loss  of  ' '  visual  images ' " 
fa  merchant  who  had  suddenly  lost_  his  visual  memory  and  the  ability  to  think  in 
French)  has  certainly  lost  a  rather  circumscribed  type  of  psychic  reactions ;  but  from 
this  to  a  theory  of  localization  of  these  functions,  there  is  a  long  distance.  One 
might  weh  expect  a  subjective  reaction  where  words  are  forgotten  different  from 
when  they  are_  supposed  to  be  "destroyed,"  but  even  this  difference  is  yet  to  be 
established,  if  it  exist  at  all. 

Wernicke's  primary  effort  is  to  establi-sh  a  tenable  non-traditional  symptomatol- 
ogy, and  in  this  I  see  his  greatness.  His  ideal  would  be  attained  beyond  doubt 
were  it  possible  to  demonstrate  that  the  symptoms  depend  upon  known  properties 
of  the  orsran  and  their  derangement  by  disease.  This  is,  however,  really  fi-uitful  of 
results  only  when  we  deal  with  accepted  knowledge  or  accepted  hypotheses.  These 
of  Wernicke  are  purely  tentative,  and  probably  more  complicated  than  is  advisable 
or  necessary. 

Wernicke  bases  his  clinical  discussions  on  a  material  of  5000  eases  observed  by 
him  and  his  assistants  during  fifteen  years.  From  this  rich  material  he  selects  cer- 
tain cases  which  appear  most  simple  and  lucid  and  open  to  thorous-h  analysis.  Only 
about  50  per  cent,  of  the  acute  psycho.ses  are  covered  ;  the  other  50  ])er  cent.  a]i]iear 
as  yet  too  complicated  for  a  text-book,  and  there  are  continually  cases  added  which 
must  be  classed  as  new  types. 


A  REVIEW  OF  RECENT  PROBLEMS  OF  PSYCHIATRY.  657 

The  feature  that  attracts  me  in  Wernicke  is  the  faithl'ul  adlierencc  to  actual  ob- 
servations of  cases.  There  are  no  composite  pictures  of  entire  groups  (in  which  it  is 
so  easy  to  juggle  the  symptoms  a  little  for  the  sake  of  creating  a  clear  picture),  bat 
always  definite  case-records  on  which  he  builds  his  discussions  and  conclusions. 
There  is  no  ready-made  coat  to  fit  all  cases  covered  by  a  traditional  name,  but  a 
statement  of  the  material  and  general  features  in  a  few  cases  and  directions  as  to  how 
to  find  and  use  these  in  others.  There  is  no  belittling  individual  traits  in  such 
descriptions,  but  there  is  an  avowed  plan,  and  much  to  help  to  distinguish  the  fun- 
damentally important  traits  from  the  merely  individual  ones. 

Wernicke  starts — very  wisely,  it  seems  to  me,  though  my  reasons  are  derived 
from  a  purely  practical  standpoint — with  the  cases  whose  mental  activity  resembles 
in  its  course  and  form  that  of  a  healthy  individual.  In  his  language,  these  are  cases 
with  changes  of  the  contents  of  consciousness  notwithstanding  normal  or  nearly 
normal  course  of  mental  activity.  His  first  type  is  recovery  without  insight — "  re- 
sidual autopsychic  falsification  of  memory  " — a  class  which  ought  to  be  recognized 
by  the  public  and  by  courts  as  not  completely  recovered  ;  the  second  one  is  that  of 
relative  recovery,  also  without  insight,  but  with  additional  delusions  of  explanation, 
of  persecution,  and  perhaps  consecutive  ideas  of  exalted  importance.  In  this  group 
he  shows  cases  of  residual  falsification  of  consciousness  either  in  all  the  three  fields 
of  consciousness  (a  total  psychosis,  auto-,  alio-,  and  somatopsychic),  or  simply  allo- 
psychic, or  somatopsychic — all  merely  cases  of  incomplete  recovery,  "old"  or 
"chronic"  cases.  These  residual  derangements  are  to  be  distinguished  from  the 
mental  disorders  of  chronic  evolution,  the  chronic  psychoses  proper.  Psychosis 
with  him  means  a  disease-process  in  activity ;  as  soon  as  it  comes  to  a  standstill 
without  recovery,  the  case  enters  the  class  of  mere  chronic  derangement. 

In  this  connection  Wernicke  demonstrates  the  importance  of  explanatory  delu- 
sions (auto-,  alio-,  and  somatopsychic)  which  arise  on  a  basis  of  autochthonous  ideas, 
or  of  motor  symptoms,  or  even  on  a  basis  of  perceptions  of  functions  which,  as  such, 
are  perfectly  normal,  such  as  the  pulse  or  heart-beat.  He  also  deals  with  hallucina- 
tions, ideas  of  reference,  the  retrospective  explanations  and  falsifications  of  memory, 
and  dominant  ideas.  -^ 

Theoretically  he  postulates  the  occurrence  of  ''''  sejnnction''  the  local  interruption 
of  sets  of  associations,  as  an  explanation  of  the  lack  of  correction  of  delusions.  The 
continuance  of  activity  of  the  remaining  functions,  without  realization  and  correction 
of  the  interruption,  leads  to  all  the  secondary  symptoms.  Falsification  pf  memory, 
and  even  hallucinations,  are  explained  in  this  way.  Owing  to  the  local  interruption 
or  sejunction,  no  correction  takes  place. 

For  an  analysis  of  this  kind,  paranoic  conditions  and  the  residual  disorders 
following  mental  disease  offer  undoubtedly  the  best  material.  It  does  seem  as  if 
there  were  a  block  in  the  way  of  the  formerly  correct  reasoning,  and  it  is  striking 
that  in  many  patients  the  lapse  is  largely  in  the  direction  of  one  of  the  three  fields 
distinguished  by  Wernicke,  the  auto-,  alio-,  or  somatopsychic  domains.  But  neither 
in  actual  correlation  with  happenings  in  the  brain,  nor  in  the  question  of  localization, 
does  Wernicke  furnish  evidence  pointing  to  any  actual  gain  in  knowledge  of  fact 
concerning  the  brain  as  such.  The  autochthonous  ideas  are  accepted  as  meteors, 
and  the  block -theory  may  satisfy  many  a  student  sufiiciently  to  relieve  him  (perhaps 
to  the  disadvantage  of  the  patient)  of  the  duty  of  finding  out  how  the  strange 
thoughts  came  into  existence,  whether  through  some  psychic  trauma  (as  undoubt- 
edly in  many  querulants)  or  through  some  other  psychic  process  worth  investigating 
with  all  the  means  at  our  command.  The  theory  also  winks  at  some  favorite 
localizations  of  hallucinations.  So  long,  however,  as  Wernicke  remains  within  the 
bounds  of  psychical  analysis  on  the  basis  of  "personality,"  and  speaks  abstractly  of 
dissolution  or  sejunction  of  personality  through  irritation  or  final  interruption 
at  certain  points  of  his  hypothetical  path  (sensory  memory  field— initial  concept — 
final  concept — motor  memory  field)  we  can  only  admire  his  genius  and  excellent 
metaphors.      Imperative   concepts    he  describes   as   an   irritation   with   preserved 

^  These  terms  recur  so  often,  are  so  useful,  and  likely  to  become  lasting  in  our 
psychiatric  phraseology,  that  a  brief  definition  is  excusable.  Autochlhonous  idea  signi- 
fies what  the  patient  usually  calls  "  a  thought  coming  in  some  unaccountable  way," 
strange,  but  not  referred  to  an  actual  hallucination.  An  idea  of  reference  is  one  where 
it  is  supposed  that  what  others  do  or  say  refers  to  one's  self,  that  trivial  events  or 
actions  mean  something  in  relation  to  one's  self,  etc.  A  dominant  idea  or  unreasonable 
idea  is  an  idea  which  has  obtained  to  undue  importance,  usually  through  its  emotional 
tone,  and  is  exaggerated,  as,  for  example,  the  ideas  of  the  crank  or  querulant. 
42 


658  MENTAL  DISEASES. 

continuity  ;  autochthonous  ideas  as  an  irritation  with  partially  dissolved  continuity  ; 
hallucinations  as  an  irritation  with  a  blockade  ;  and  finally  he  tells  us  of  simple 
sejunction  without  irritation — the  mere  residual  uncorrected  state.  The  inter- 
changeability  of  autochthonous  ideas  and  of  hallucinations,  and  the  possibility  of' 
persistence  of  hallucinations  beyond  the  florid  active  period  of  the  disease,  is 
' '  explained ' '  by  sejunction. 

The  acute  psychoses  yield  to  a  great  extent  to  the  same  principles  of  analysis. 
Wernicke  sees  the  acuteness  in  the  rapidity  of  evolution  ;  acute  psychoses  are 
changes  of  the  contents  of  consciousness  which  we  see  develop  within  a  definite  time. 
Such  changes  are  usually  marked  by,  and  frequently  obscured  by,  deep  emotions 
and  affects.  The  rapidity  of  the  change  stamps  the  attacks  in  another  way.  While 
in  the  chronic  paranoic  condition  the  lasting  or  fixed  perversions  of  the  contents  o^ 
consciousness  are  uppermost,  the  morbid  changes  of  activity  of  consciousness 
characterize  the  acute  psychoses. 

Wernicke  offers  no  complete  ' '  general  symptomatology. ' '  True  to  his  principle. 
Wernicke  presents  his  analysis  in  connection  with  the  record  of  an  actual  recovered 
case,  a  very  well-educated  person  who  remembers  and  analyzes  his  sj^mptoms 
excellently.  We  again  meet  with  sejunction  and  delusions  and  hallucinations  and 
autochthonous  ideas.  Their  coherence  and  durability  depend  on  a  certain^ degree  of 
connection,  and  on  the  possibility  and  extent  of  the  mental  funds.  Wernicke  shows 
us  new  sources  of  delusions :  some  that  result  from  conclusions  of  analogy,  some 
from  inattention,  and  some  that  originate  from  morbid  new-formation  of  associa- 
tions. He  discusses  simple  and  compound  hallucinations  and  the  various  theories 
of  hallucination.  For  Wernicke  a  hallucination  is  due  to  the  wiping  out  of  the 
difference  between  a  memory-picture  and  the  picture  of  actual  perception,  which 
depends  on  perception-cells,  the  bearers  of  the  organic  feeling  which_  belong  to  each 
actual  sensation,  and  constitute  the  "  somatic  consciousness."  Their  activity  gives 
the  picture  its  reality,  forces  it  into  the  center  of  attention  (as  is  the  case  with  all 
the  derivatives  of  somatic  consciousness).  The  point  of  attack  of  the  irritation 
must  be  those  locahties  which  con-espond  to  the  memoiy-images  and  the  effect 
spreads  over  entire  "  Merksysteme, "  or  concatenations  of  (neuro-)  psychic  elements, 
and  of  the  perception  cells.  Abnormal  conditions  of  the  latter  may  show  in 
hallucinations.  Thus,  Pick  observed  a  patient  who  formerly  _  had  had  sensory 
aphasia,  with  auditory  hallucinations  of  a  distinctly  paraphasic  character  ;  and 
another  patient  with  a  hemiopic  defect  of  homonymous^  quadrants  saw  a_  defect  of 
the  corresponding  sector  in  the  hallucination  of  a  face.  The  irritation  in  one 
hemisphere  is  probably  .sufficient ;  visions  appear  flat ;  voices  seem  much  more  real 
because  the  auditory  center  is  one-sided,  in  the  left  temporal  lobe.  Certain  forms 
of  compulsoiy  talk  are  probably  a  direct  .symptom  of  lesion  of  the  left  temporal  lobe. 
But  the  irritation  is,  as  a  rale,  of  the  nature  of  irradiation  from  processes  of 
sejunction  otherwise  localized ;  for  the  same  types  of  disease  may  occur  with  or 
without  phonema  (=  auditory  haUucination  in  words),  and  in  one  and  the  same  case 
the  contents  may  be  expressed  as  a  voice  or  come  merely  as  a  thought.  The  special 
localization  of  "memories"  seems  fairly  well  proved  to  Wernicke,  and  also  the 
possibility  of  thought  by  means  other  than  the  left  temporal  lobe.  The  distinction 
between  phonema  and  autochthonous  idea  (which  usually  comes  in  definite  words, 
and  therefore  might  be  a  symptom  of  irritation  of  the  left  temporal  lobe)  is  referred 
to  a  hypothetically  different  localization  of  the  sejunction. 

The  primary  identification  may  also  be  affected  in  insanity  (Wernicke  includes  in 
the  mechanism  of  primary  identification  the  activity  of  the  perception-cehs  and  the 
act  of  conduction  to  the  memory-cells,  the  secondary  identification  is  merely  the 
transcortical  conduction  beyond  the  memory-cells)  :  (1)  In  hypermetamorphosis,  a 
term  derived  from  Neumann,^  meaning  compulsory  distractibilit}',  due  to  increased 
irritability  of  the  naturally  dominating  organic  sensation,  i.  «. ,  actual  vision,  actual 
hearing,  etc. ;  this  sensitiveness  may  implicate  more  or  less  either  hearing  or  vision  ; 
it  always  leads  to  distraction  and  disconnection  of  the  stream  of  thoughts  and  it 
is  a  chief  constituent  of  confusion  (see,  however,  Wernicke,  p.  221,  1).  (2)  In 
hyperesthesia  of  the  sense-organs,  chiefly  in  hysterical  patients  and  at  the  onset  or 
during  convalescence.  Only  hypermetamorphosis  is  of  importance,  and  it  occurs, 
outside  of  agitated  phases  of  general  paralysis,  chiefly  in  severe  forms  of  confused 

1  In  his  excellent  little  "Leitfaden  der  Physiatrie  "  he  speaks  of  the  drift  and 
stream  of  activity  and  thought  as  metamorphosis  ;  too  rapid  a  drift  he  calls  hyper- 
metamorphosis, whereas  states  of  absorption  and  inactivity  are  called  ametamorphosis^ 


A  REVIEW  OF  RECENT  RROBLEMS  OF  PSYCHIATRY.  659 

mania  and  in  hyperkinetic  motility-psychoses.  Anotlier  set  (jf  symptoms  not 
strictly  belonging  in  the  grou])  of  disorders  of  sec(Hidaiy  identification  is  of  the 
same  order  as  numerous  automatic  motor  adjustments,  like  normal  visual  fixation, 
or  reactions  of  defense  in  emotion,  and  in  mental  disease,  jactations,  motions  of  ex- 
l^ression,  attitudes  of  anxiety  of  variable  localization,  motor  unrest  or  states  of 
rigidity  or  akinesis,  perhaps  in  analogy  with  what  may  come  from  pressure 
on  internal  organs.  (Wernicke  refers  to  the  profound  effects  of  pressure  on  the 
kidney,  etc.) 

Wernicke  next  deals  with  the  concept  of  "disorientation."  The  disorders  of 
identification  bring  about  a  condition  which  Wernicke  calls  disorientation,  and 
according  to  the  sphere  of  consciousness  in  which  the  provoking  changes  occur  he 
speaks  of  _  autopsychic,  allopsychic,  somatopsychic,  and  motor  disorientation. 
Wherever  it  sets  in  rapidly,  it  throws  the  patient  into  a  vivid  aifect  of  perplexity 
and  puzzle.  That  the  hallucinations  as  such  do  not  necessarily  produce  disorientation 
in  the_  ordinary  sense  of  the  word,  Wernicke  shows  in  two  patients,  one  of  whom  is 
an  epileptic  with  most  vivid  hallucinations,  but  perfect  recognition  of  people  and 
place,  etc.  Among  the  various  types,  somatopsychic  perplexity  is  most  absorbing. 
It  is  possible  that  the  localized  feeling  of  anxiety  is  meiely  a  type  of  somatopsychic 
perplexity.  Also  the  acts  of  perplexity  are  described.  The  same  case  presented 
also  peculiar  motions  which  Wernicke  calls  pseudo-spontaneous  motions  (analogous 
to  autochthonous  ideas),  unaccountable  motions,  felt  as  strange  by  the  patient,  also 
normally  subject  to  explanatory  delusions.  The  same  patient  attributes  the  initiative 
and  reactive  mutism  merely  to  a  certain  difficulty  of  speech,  not  to  any  orders  of  the 
voices.  _  He  remembers,  however,  his  surprise  over  certain  circumscribed  parakinetic 
and  akinetic  states,  and  that  concerning  them  he  had  the  idea  that  God  put  them 
on  him.  In  a  further  lecture,  Wernicke  points  to  the  dominant  ideas  and  a  specific 
type  of  special  sensitiveness  (compared  to  the  sensitiveness  of  a  sleeping  mother  to 
any  noise  from  the  child),  palled  partial  intrapsychic  hypermetamorphosis.  Finally^ 
he  gives  his  reasons  for  thinking  that  the  form  of  both  illusions  and  hallucinations 
is  usually  the  expression  of  an  aff"ect,  and  that  the  form  and  content  are  determined 
by  the  dominant  idea,  or  by  the  auto-,  alio-,  or  somatopsychic  or  motor  perplexity. 
After  a  thorough  analysis  of  the  rather  complex  case  which  Kraepelin  would  call  a 
catatonia  with  remission,  he  begins  the  description  of  a  series  of  types  and  goes  on 
witli  their  analysis. 

Throughout,  Wernicke  aims  at  explanation  of  symptoms  based  upon  the  known 
functions  of  the  organ.  He  makes  good  use  of  those  excellent  studies  of  his  pupils 
on  asymbolia,  etc.,  and  one  feels  that,  at  the  same  time,  he  is  wide  awake  to  the 
facts  of  the  case,  and  in  this  respect  at  least  perfectly  true  to  his  promise  to  put  the 
observation  of  the  case  into  the  foreground  and  to  adapt  the  method  of  interpreta- 
tion to  the  needs.  His  descriptions  are  very  faithful  and  the  new  nomenclature 
shown  in  them  by  no  means  mere  form.  There  is  no  alienist  who  would  not  like  to 
throw  oifmany  of  the  terms  of  descriptive  cant  seen  in  the  case-records  of  hospitals; 
but  the  difficulty  is  how  to  replace  them.  Wernicke  has  certainly  given  us  a  splen- 
did and  useful  help  in  his  broadening  out  of  the  term  disorientation  (perhaps,  better, 
inadequacy  of  attitude  and  reaction)  to  all  loss  of  bearings  in  any  sense  whatever,  as 
the  l\indamental  trait  of  all  insanity.  And  his  next  step,  the  recognition  of 
"perplexity,"  is  equally  important  as  a  topic  of  analysis  where  current  nomencla- 
ture uses  the  terms  '" confusion "  and  "depression  "  without  any  further  inclination 
to  show  what  the  trouble  consisted  in.  His  series  of  "dominant  ideas,"  imperative 
ideas,  autochthonous  ideas,  phonema,  and  "  pseudo-spontaneous  motion  "  is  another 
clearing  factor.  The  division  of  the  realm  of  consciousness  into  facts  referring  to 
the  patient's  personality,  to  his  body,  and  to  the  outside  world  and  its  living  and 
non-living  factors  appears  perhaps  dogmatic,  but  is  over  and  over  again  shown  to  be 
of  fundamental  importance  owing  to  the  totally  diff'erent  causal  efficiency  and  symp- 
tomatic value  of  the  three  types — which,  by  the  way,  Wernicke  does  not  mean  to 
distinguish  absolutely,  at  the  expense  of  justice  to  facts,  as  he  is  quite  willing  to  see 
transitions  where  they  occur.  And  when  we  look  at  such  a  condition  as  delirium 
tremens,  it  is  really  striking  how  the  limitation  as  a  psychosensory  allopsychosis 
opens  one's  eyes  to  a  very  distinctive  feature. 

The  intense  neurological  interests  of  Wernicke,  however,  give  his  analysis  a 
peculiar  trait  which  has  its  disadvantages.  The  emphasis  on  localization,  the  pre- 
occupation by  "spatial"  analysis,  does  not  quite  do  justice  to  a  field  which  is  so 
eminently  a  stream  of  occurrences.  However  broad  a  place  the  localizing  discussions 
occupy,  in  reference  to  the  auto-,  alio-,  somatopsychic  and  motor  disorders,  they 


660  MENTAL  DISEASES. 

fiiruish  little  nosological  result.  The  localization  of  the  organic  or  corporeal  com- 
ponent of  sensations  in  the  cells  nearest  the  marrow,  the  consideration  that  hallu- 
cinations must  involve  memory  fields  and  i^ercei^tion-cells,  may  supply  serviceable 
suggestions  for  our  phraseology  as  to  brain-happenings  ;  but  as  long  as  the  all- 
important  sejunction  is  somewhere  else  or  anywhere,  the  localizing  factor  in  the 
description  is  largely  decorative,  and,  as  I  mentioned  before,  is  apt  to  be  deceptive 
and  distracting.  The  sejunction  is  a  formula.  There  are  absolutely  no  facts  for  its 
analysis  outside  of  what  we  observe  in  the  development  of  the  symptoms,  and  if  we 
wish  togoljehind  the  symptomatic  sejunction, — i.  e.,  behind  the  evidence  of  what  we 
have  in  the  way  of  facts  in  the  form  of  a  stream  of  events, — we  merely  find  an 
improbable  something  in  the  form  of  an  unknown  lesion.  We  shall  recur  to  this 
again.  For  the  time,  we  repeat  our  expression  of  indebtedness  to  Wernicke,  for 
having  shown  us  a  way  to  emancipate  ourselves  from  traditional  haziness,  and  for 
giving  us  some  points  of  view  which  may  have  some  value  when  our  knowledge  ot 
correlation  of  brain  and  mind  becomes  a  more  useful  and  imperative  problem  than  it 
is  now,  for  want  of  facts. 

The  consequences  of  the  "  spatial  "  interests  show  clearly  in  Wernicke's  presen- 
tation of  the  disease  types.  But  he  gives  most  excellent  sketches  of  temporary 
states — just  what  one  needs  and  wants  to  get  at  in  actual  life  in  examining  a  patient. 
His  descriptions,  as  far  as  I  am  aware,  have  no  equal  in  the  entire  literature  of 
psychiatry.  Everywhere  we  see  a  pi'esentation  of  the  palpable  observations,  and 
only  that  which  is  expressed  by  the  patient  and  actually  established  by  the  physician 
is  used  for  the  analysis.  There  is  no  resorting  to  assumed  anemias  and  hereditary 
predispositions,  or  to  degeneracy,  or  even  to  better  established  etiology,  as  long  as 
the  examination  of  the  symptomatology  goes  on  ;  nothing  is  suggested  as  expected 
to  exist  "in  such  cases,"  as  would  happen  if  he  started  from  set  tradition;  and 
since  he  sticks  to  his  one  case,  he  does  not  tire  and  confuse  one  with  the  statement 
that  this  and  that  symptom  "may  occur."  In  this  respect  Wernicke  approaches 
the  ideal  exemplified  in  his  colleague  Foerster,  to  whom  he  has  paid  a  most  worthy 
tribute  in  admitting  his  great  indebtedness  to  him.  Wernicke  goes  so  far  as  to  say 
that,  with  his  excellent  method  of  examination  and  discrimination  of  clinical 
symptoms,  Foerster  would  have  established  all  the  forms  of  amaurosis  and  their 
clinical  value  from  a  mere  study  of  the  functional  disorders,  even  if  the  ophthalmo- 
scope had  never  been  discovered.  And  Wernicke  drew  the  natural  conclusion  that 
in  a  field  where  an  "  encephaloscope  "  is  not  to  be  hoped  for,  an  accurate  study  of 
symptomatology  is  all  the  more  needed,  furnishing,  as  it  does,  a  means  of  getting  out 
of  what  he  caWs '^  die  psychiatrische  llish-e.^' 

The  first  type  Wernicke  describes  is  the  anxiety  psychosis,  a  type  which  is  usually 
called  agitated  melancholia.  This  form  of  depression  resolves  itself  chiefly  into 
anxiety  and  perplexity.  A  perusal  of  his  cases  and  their  analysis  and  comparison 
with  his  "'affective  melancholia"  and  the  conscientious  description  of  a  group  of  in- 
termediate cases  shows  one  at  once  his  whole  attitude,  which  is  one  not  bent  on 
classifications,  but  on  understanding  of  the  case.  The  anxiety  psychoses  are  brought 
into  close  relation  with  the  somatopsychoses  and  hypochondriacal  disoi-ders,  forming 
a  group  of  cases  that  usually  appears  in  our  statistics  as  "  melanchoha. " 

The  next  type  is  acute  hallucinosis,  followed  by  the  sensory  allopsychosesof  which 
delirium  tremens  is  a  prototype  ;  then  comes  the  group  of  autopsychoses  including 
certain  hysterical  states,  certain  forms  of  Wahnsinn,  and  imperative  concepts.  Next, 
Wernicke  describes  affective  melancholia  and  simple  mania ;  then  hyperkinetic 
motility  psychoses ;  then  confused  mania  ;  further,  akinetic  motility  psychoses ; 
later  certain  compound  forms  ;  and,  finally,  as  a  group  on  an  etiological  basis,  general 
paralysis.  Finally  he  reviews  other  etiological  groups,  the  course  and  outcome,  and 
dissimulation  and  simulation,  and  the  outlook  in  the  direction  of  a  pathological- 
anatomical  understanding  of  mental  disease. 

We  now  turn  to  KraepeHn.  The  literary  antecedents  of  his  1896  edition  He_  in 
the  direction  of  the  psychological  experiment  and  of  clinical  psychiatry.  His  chief 
contributions  to  science  are  :  (1)  Studies  of  the  influences  of  alcohol  and  other  sub- 
stances on  mental  activities,  begun  in  Leipzig  under  the  influence  of  Wundt._  (2) 
Studies  of  a  clinical-etiological  character.  ^  (3)  Descriptive  and  analytical  studies  of 
disorders  of  memory.^     (4)  The  various  editions  of  his  text-book  (1880-1899). 

The  first  edition  of  the  text-book  was  the  first  extensive  publication.     It  stands 

^  "Arch.  f.  Psychiatrie, "  vols,  xi  and  xii. 

-  "Arch.  f.  Psvchiatrie, "  vols,  xvii  and  xviii. 


A  HE  VIEW  OF  RECENT  PROBLEMS  OF  PSYCHIATRY.  661 

thoroughly  uu  Wuiidt's  giuuuds  in  its  general  pait,  and  in  the  special  part  ranges 
itself  at  once  with  the  works  that  furnish  descriptions  of  types  of  events  with  little 
reference  to  individual  cases.  The  isolation  to  Wundt  gave  the  book  the  stamp  of 
the  most  up-to-date  attempt  at  psychopathology,  and  it  was  rec(jmmended  in  my 
years  of  study  as  the  best  psychologically,  while  KraflFt-Ebing  was  commended  as 
most  excellent  clinically,  although  to  my  mind  Schiile  would  probably  have  deserved 
the  first  recommendation  for  descriptive  accuracy  (it  is,  however,  rather  more  true 
to  nature  and  more  complete  than  is  good  for  the  student).  My  personal  reminis- 
cence of  the  third  edition  of  Kraepelin  is  that  of  a  systematic  and  very  readable  work, 
but  not  of  the  kind  that  would  have  evoked  in  any  one  such  a  distinct  feeling  of 
contrast  with  other  books  and  clinical  teachings,  as  the  last  two  editions  have  pro- 
voked. 

The  striking  feature  of  the  book  was  the  marked  change  which  occurred  from 
edition  to  edition,  and  the  gradual  growth  of  what  was  at  first  a  small  compend  to  a 
work  consisting  of  two  large  volumes  and  treatmg  the  subject  from  a  totally  different 
standpoint. 

As  the  neurological  study  of  the  brain  and  the  extension  of  neurological  views 
into  psychiatry  mark  Wernicke's  work,  so  do  psychological  experiment  with  drugs 
and  its  method  of  investigation  show,  in  a  way,  all  through  Kraepelin' s  work.  The 
working  of  the  minds  of  the  two  investigators  is  distinctly  expressed  by  their 
chief  interests  in  research.  Their  method  in  psychiatry  is  described  by  both  as 
essentially  clinical.  We  have  shown  it  in  our  review  of  Wernicke,  and  Kraepelin 
claims  for  his  whole  recent  tendency  the  distinctive  term  "clinical,"  with  much 
justification  (in  a  specific  sense,  which  is  best  illustrated  by  the  simile  of  longitudinal 
sections  of  the  cases,  i.  e. ,  the  study  of  the  entire  course  of  the  disease  is  expected 
to  reveal  its  true  nature,  rather  than  the  mere  cross-section,  the  temporary  picture 
of  just  one  phase  or  episode  by  itself).  Wernicke  starts  from  thoroughly  analyzed 
observations  of  individual  specific  cases,  Kraepelin  from  groups  of  cases.  Only  in 
his  "Leitfaden,"  published  in  1900,  does  Kraepelin  give  complete  records  of  indi- 
vidual cases,  and  these  are  mostly  analyzed  from  the  point  of  view  of  course  and 
outcome.  There  is  nowhere  a  careful  analysis  of  the  "contents  of  consciousness," 
in  Wernicke's  sense  of  this  phrase,  but  there  is,  on  the  other  hand,  a  most  consci- 
entious analysis  of  the  form  of  the  stream  of  mental  events,  and  of  general 
symptomatology.  He  makes  the  sequence  of  events  the  main  point,  as  in  an  experi- 
ment. 

This  emphasis  of  the  stream  of  events  points  to  a  training  obtained  through  the 
practice  of  experimentation.  It  supplements  Wernicke's  localizing  analyses  in  a  very 
important  way,  and  (as  the  reading  of  Kraepelin  would  lead  one  to  think)  perhaps 
even  replaces  them  essentially.  Wernicke  shows  us  the  patient  as  representative  of 
a  group  of  symptoms  in  a  topographic  arrangement  more  or  less  in  harmony  with 
the  problems  of  localization.  Wernicke's  conscientious  adhesion  to  the  facts  does 
not  fail  to  represent  the  symptoms  as  a  chain  of  events  ;  but  the  light  is  expected 
from  grouping  the  symptoms  topographically — either  according  to  divisions  of 
one's  mental  world,  into  auto-,  alio-,  and  somatopsychoses,  or  according  to  localizing 
schemes  in  the  brain  (sejunction)  or  organism.  It  is  a  chain  with  the  links  simul- 
taneously before  us,  not  a  stream^  concerning  which  we  would  naturally  be  interested 
mostly  in  the  direction  and  source  and  aim  of  the  current.  In  Kraepelin  the 
chronological  side  prevails,  as  it  were ;  and  from  the  fifth  edition  he  says  practi- 
cally :  It  is  the  sequence  of  events  that  is  of  medical  importance  ;  the  prognosis,  the 
outcome,  is  the  issue,  and  traits  in  the  sequence  of  events  are  from  the  start  the  best 
material  upon  which  to  build  nosological  conclusions.  With  Wernicke,  the  exist- 
ence of  anxiety  leads  to  the  creation  of  an  anxiety  psychosis,  in  which  he  distin- 
guishes allopsychic  and  somatopsychic,  intestinal,  ascending  and  diifuse  forms,  and  a 
paralytic  type — a  group  which  includes  acute,  subacute,  and  chronic  disorders  of 
totally  different  nature,  to  be  diff'erentiated  in  each  individual  case.  Anxiety 
appears  as  a  fundamental  symptom  in  almost  every  cross-section.  Kraepelin  divides 
these  cases  into  totally  different  groups — into  involution  melanchoHa,  into  forms  of 
dementia  prgecox,  and  formerly  also  paranoia,  according  to  the  nature  of  the  course 
and  especially  the  outcome  of  the  disease. 

In  Ziehen,  too,  we  find  much  reference  to  sequences,  but  in  a  much  more 
restricted  sense.  While  Wernicke  divides  the  facts  of  observation  into  groups  of 
practical  importance,  relatively  free  from  traditional  psychology,  merely  obeying  the 
demands  of  his  clinical  sense  and  neurological  habits,  Ziehen  groups  them  according 
to  his  psychology,  which  shines  rather  by  its  formal  logical  finish  than  by  considera- 


662  3IENTAL  DISEASES. 

tion  of  the  special  demands  of  medical  experience.  He  places  emotional  life  and 
intellect  in  two  distinct  categories  ;  and  mental  disorders  are  classified  into  affective 
and  intellectual  forms,  and  in  a  more  fundamental  way  into  those  without  and  those 
with  intellectual  defect  (the  dementias).  This  strictly  analytical  psychological  plan 
has  its  clinical  justification  to  some  extent,  and  it  employs  certain  principles  of 
chronological  sequence  of  development  to  some  advantage.  For  instance,  experience 
shows  that  it  is  quite  a  different  thing  whether  depression  sets  in  and  is  followed  by 
delusions,  or  whether  delusions  set  in  and  are  followed  by  some  depression.  This 
is  a  principle  of  sequence  quite  extensively  used.  Kraepelin's  observation  of 
sequences  refers,  however,  much  more  to  elementary  biological  facts,  and  is,  as  such, 
independent  of  psychological  systems.  The  most  distinctive  part  is  the  description 
of  streams  of  psychic  events.  That  Kraepelin  still  adheres  to  Wundt's  general 
plan  of  classification  of  psychology  in  his  general  symptomatology,  I  consider  quite 
accidental,  and  of  no  positive  consequence  whatever,  although  I  admit  that  it  has 
certain  distractive  consequences.  Without  Wundt's  psychology,  Kraepelin  would 
much  more  likely  break  through  to  a  less  formal  presentation  and  shape  his  general 
part  into  more  profitably  arranged  matter. 

For  years  Kraepelin  has  been  at  work  studying  the  effect  of  drugs  and  of 
fatigue  and  other  influences  on  the  trend  and  form  of  mental  reactions.  For  this 
purpose  he  has  systematized  experimental  tests,  from  which  he  derives  his  informa- 
tion in  a  number  of  directions  which  are  really  more  modifications  of  general  biolog- 
ical traits  than  topics  of  logical  analysis  of  psychological  products.  His  data  refer 
mostly  to  the  amount  and  efficiency  of  work,  as  shown  by  the  ergograph  experiment, 
additions,  reading,  association-tests,  and  the  effects  of  practice  and  fatigue. 

These  data  play  a  great  part  in  the  examinations  of  his  cases.  The  stream  of 
thought  and  its  deviations  from  the  normal  are  indeed  as  prominent  with  him  as  the 
classification  of  the  contents  of  consciousness  and  the  disorders  of  orientation  are 
with  Wernicke.  The  large  group  of  manic-depressive  insanity  is  made  up  of  cases 
in  which  symptoms  of  inhibition  of  thought  or  of  flight  of  ideas,  stand  out  charac- 
teristically beside  emotional  and  motor  changes.  This  group  is  the  best  founded 
entity  of  the  Heidelberg  school.  Clinical  experience  shows  that  the  traits  described 
mark  conditions  which  do  not  pass  into  dementias  and  which  stand  out  for  other 
reasons  (belonging  to  the  typically  ' '  clinical ' '  trend  of  thought)  as  a  disease-entity 
clearly  distinct  from  the  large  group  of  dementia  praecox. 

Kraepelin  had  publicly  declined  the  method  of  Ziehen  and  expressed  his  disbe- 
lief that  what  we  called  above  "logical  psychology  "  could  be  of  any  real  value  in 
psychiatric  nosology.  He  especially  criticized  Ziehen's  paranoia  group  in  his  review 
in  the  "  Zeitschrift  fur  Nei-venheilkunde,"  as  bringing  together  essentially  chronic 
conditions  and  acute  psychoses  of  a  totally  different  stamp,  simply  because  the  dis- 
order happened  to  be  in  the  field  of  the  intellect,  as  Ziehen  defines  it,  and  because 
the  cross-section  has  certain  similarities. 

The  emancipation  of  manic-depressive  insanity  from  the  rest  of  the  acute 
psychoses  brought  about  an  interesting  revolution.  It  implied  the  creation  of  a 
group  on  symptomatic  foundation  and  at  the  same  time  with  a  definite  prognostic 
forecast.  This  coincidence,  and  the  practical  advantage  derived  from  it,  had  so  far 
been  the  distinction  of  only  three  forms  of  disease — of  general  paralysis,  of  paranoia 
(in  the  sense  of  a  chronic  delusional  transformation),  and  of  senile  dementia.  The 
result  of  singling  out  manic-depressive  insanity  was  that  climacteric  melancholia  had 
to  be  separated  from  manic-depressive  melancholia,  and  that  a  certain  number  of 
"acute  psychoses"  were  grouped  with  the  usually  subacute  "psychoses  of  deteriora- 
tion" on  account  of  their  usual  outcome,  although  in  a  certain  number  of  them 
deterioration  was  not  sufficiently  certain.  The  exhaustion  psychoses  remained,  but 
in  practice  they  were  found  less  frequently  because  many  cases  formerly  classified 
as  such,  showed  the  distinguishing  features  of  manic-depressive  insanity,  or^of 
psychoses  of  deterioration. 

All  through,  general  paralysis  becomes  the  one  paradigm  of  a  mental  disease,  and 
the  traditional  forms  are  called  symptom -complexes,  unless  they  fulfil  the  require- 
ment of  definite  etiology,  coui'se,  and  outcome.  From  the  point  of  view  of  mental 
symptoms,  as  such,  general  paralysis  gives  indeed  the  greatest  possible  latitude. 
What  distinguishes  general  paralysis  had  to  lie,  as  most  alienists  say,  either  in  the 
addition  of  the  projection  symptoms  or  neurological  symptoms  which  characterize 
general  paralysis,  or  in  the  differences  of  mental  symptoms,  inasmuch  as  on  close 
observation  there  is,  after  all,  in  paralytic  paranoia,  paralytic  circular  insanity,  or 
paralytic   delirium,   a   certain   something  which  usually  makes  it  possible  to  dis- 


A  REVIEW  OF  RECENT  PROBLEMS  OF  PSYCHIATRY.  663 

tinguish  them  from  simple  paranoia,  manic-depressive  insanity,  or  delirium.  Krae- 
peim  seems  to  favor  the  latter  view  in  his  effort  to  show  that  even  from  the  mental 
sj'mptoms  one  can  make  a  diagnosis  of  general  paralysis,  and  he  emphasizes  just 
these  distinguishing  features.  A  further  step  was  that  other  conditions  in  which  it 
W(juld  be  possible  to  draw  conclusions  from  special  marks  of  the  symptom-complex 
(the  cross-section),  as  to  etiology,  c(jurse,  and  outcome  (the  longitudinal  section), 
could  be  also  classed  as  diseases — and  only  these. 

The  relatively  small  material  of  the  Heidelberg  clinic,  and  the  fact  that  it  is  fed 
by  a  district  which  is  easily  accessible  and  furnishes  extensive  records  of  the  pa- 
tients' tamilies  and  relatively  uniform  conditions  of  life,  render  it  in  most  respects 
ideal  for  an  extensive  study  of  what  the  patients  were,  are,  and  prove  to  be,  in  the 
subsequent  years  of  their  lives.  These  are  points  which  Kraepelin  made  all- 
important  as  a  test  of  his  views.  Few  investigators  are  as  favorably  situated  and, 
indeed,  few  were  prepared  to  bring  Kraepelin' s  views  to  a  test  on  their  own  material. 
Moreover,  the  sense  for  the  distinctions  of  the  stream  of  thought  which  Kraepelin 
makes  is  not  easy  to  acquire.  The  reception  which  he  found  was  necessarily 
dependent  on  other  factors  as  well ;  but  nobody  can  fail  to  recognize  with  Wernicke 
that  his  presentation  has  found  the  greatest  appreciation,  especially  among  the 
younger  generation  of  alienists.  Whether  this  is  due  to  their  inexperience  or  to 
the  tickling  of  the  palate  of  beginners  with  promises  of  prognostic  _  precision,  or 
whether  it  is  due  to  the  dogmatism  of  older  alienists  and  a  sort  of  pessimistic  vanity 
on  their  part,  it  will  be  our  task  to  find  out.  To  me,  personally,  it  has  seemed  from 
the  bednning  to  be  the  most  stimulating  guide  available  for  hospital-physicians,  an 
excellent  ladder  on  which  to  climb  out  of  the  indifi"erence  of  traditional  statistics 
and  the  apparent  hopelessness  of  even  our  best  eiforts  at  accomplishment.  Nobody 
in  this  country  has  shown  as  clearly  as  August  Hoch  how  valuable  Kraepehn  s 
principles  are  for  one  sensitive  to  deviations  from  the  normal  stream  of  thought. 
With  the  greatly  varied  and  much  larger  and  consequently  less  thoroughly  studied 
material  of  the  Worcester  Insane  Hospital,  I  found  many  difficulties,  but  Krae- 
pelin's  principles  proved  most  valuable  aids  in  my  efi"orts  to  collect  material  upon 
which  to  base  my  own  psychiatric  views. 

I  have  frequently  been  struck  by  the  difficulty  whichmany  alienists  have  in  their 
attempts  to  assimilate  and  correctly  rate  the  new  acquisitions.  If  we  analyze  briefly 
what  Kraepelin  says  of  the  differential  diagnosis  of  various  disease-types,  we  see 
everywhere  strong  emphasis  laid  on  certain  fundamental  traits,  many  of  which  have 
been  casually  mentioned  by  former  writers,  but  which  are  here  brought  into  a  closer 
connection  ;  instead  of  being  mentioned  as  accompanying  features,  theybecome  dis- 
tinctive traits  of  entire  groups.  These  groups  are  created  for  a  definite  purpose, 
which  is  largely  prognostic,  and  Kraepelin  shows  that  distinctive  traits  are  available 
and  deserveto  be  pushed  to  the  front.  What  puzzles  the  reader  is  that  the  terms 
which  they  find  are  in  part  old  acquaintances  to  which  little  meaning  has  been 
attached,  and  which  are  not  very  coherent  from  any  point  of  view  of  locahzation, 
nor  always  clear  in  their  origin.  It  takes  close  inspection  to  see  that  the  old  vague 
terms  must  be  understood  with  new  definitions  and  restrictions.  Much  of  the 
difficulty  comes  from  Ki-aepelin's  aversion  to  assimilating  the  views  of  other  men 
in  a  more  than  passing  way  (the  remarks  on  Magnan,  vol.  ll,  p.  199,  are  an 
exception).  It  would  be  so  much  easier  to  understand  him  clearly  if  we  knew  how 
he  deals  with  what  we  assume  to  know  clearly  ourselves  or  see  as  accepted  property 
of  the  literature.  Unless  this  is  done,  the  uninitiated  reader  wih  approach  the  task 
and  discover  in  the  writings  of  Kraepelin  chiefly  those  points  to  which  they  are 
positively  or  negatively  sensitive.  Kraepelin  certainly  does  not  help  one  to  start 
from  generally  accepted  views.  There  is,  moreover,  a  decided  dogmatism,  perhaps 
more  in  certain  followers  of  Kraepelin,  than  in  Kraepelin  himself,  a  non-compro- 
mising attitude  which  makes  it  difficult  to  take  in  his  very  sweeping  changes  of  the 
tenets  of  psychiatry. 

Perhaps  too  much  is  expected  from  Kraepelin' s  method.  _  Wernicke  frankly 
refuses  to  attempt  a  classification  of  cases,  but  off"ers  a  description  and  an  analysis 
.  of  manifestations  such  as  everybody  will  be  able  to  recognize  again  and  to  verify. 
About  50  per  cent,  of  the  acute  cases  yield  readily  to  this  plan.  Kraepelin,  however, 
has  larger  groups  which  would  seem  to  offer  a  greater  guarantee  that  most  cases  can 
be  classified.  He  does  not  insist  enough,  as  a  cautious  teacher  should  do,  on  the 
existence  of  an  irreducible  residuum,  such  as  all  honest  statistics  should  ruake  pro- 
vision for,  and  his  followers  are  apt  to  become  imbued  with  the  idea  that  while  it  may 
be  difficult  to  classify  many  cases  in  the  current  official  statistics,  Kraepelin' s  stand- 


664  MENTAL  DISEASES. 

l^oint  allows  of  classification  in  practially  eveiy  case.  I  plead  guilty  myself  to  sucli 
a  tendency  in  the  past ;  but  I  make  the  requirements  of  official  statistics  responsible 
fur  this,  not  Kraepelin's  teachings.  In  order  to  do  him  justice,  one  must  remember 
remarks  like  the  following  (vol.  ll,  p.  2):  "While  it  is,  therefore,  necessary  to 
leave  out  of  account — for  all  time  to  come — a  smooth  classification  of  mental  dis- 
orders of  the  nature  of  Linne's  botanical  system,  and  even  to  feel  resigned,  at  least  for 
the  present,  concerning  the  establishment  of  scientifically  well-founded  types,  there  is 
nevertheless  a  practical  need  for  at  least  an  approximate  grouping  of  the  empirical 
raw  material.  Its  value  will  be  all  the  more  lasting  the  less  it  is  influenced  bj'  pre- 
conceived opinions  in  a  sober  digestion  of  facts."  Or  vol.  n,  p.  205,  in  the  final  dis- 
cussion on  dementia  praecox  :  ' '  Whether  dementia  praecox,  in  the  scope  given  it  here, 
presents  one  disease,  must  remain  doubtful  for  the  present  at  least.  It  would  com- 
prehend about  14  or  1.5  per  cent,  of  all  the  admissions,"  etc. 

We  also  find  repeatedlj'  the  admission  of  great  difiiculty  in  diiferential  diagnosis 
and  considerably  more  caution  than  could  be  inferred  from  some  of  his  followers. 
The  danger  for  the  purity  of  his  vieics  comes  from  the  admittedly  practical  aim  and 
from  the  fact  that  prognosis  is  made  such  an  important  part  of  the  diagnosis.  The 
didactic  maxim  is  no  longer  chieflj'  that  of  sober  analysis  of  what  comes  up  in  the 
empirical  field,  and  a  division  into  what  is  understood  scientificially.  and  what  not. 
The  question  to  be  solved  is  one  of  prognosis,  which  must  anyhow  be  answered  at 
least  tentatively  in  every  case.  To  be  sure,  this  most  stimulative  feature  of  Kraepe- 
lin's teachings  can  be  used  most  profitably.  It  is  well  to  make  good  use  of  our 
natural  inclination  to  formulate  a  prognosis  and  to  say  why  we  surmise  the  one  out- 
come or  the  other,  and  that,  instead  of  vague  generalities,  we  should  aim  to  record 
as  far  as  possible  traits  which  can  be  demonstrated  in  the  patient  at  any  time,  or  at 
least  facts  accurately  written  down  in  the  histoiy,  not  general  phrases  and  intangible 
intuitions  as  the  foundation  of  prognosis.  This  is  part  of  the  eminently  didactic 
and  progressive  turn  he  gives  to  all  work  done  according  to  his  maxims.  But  every 
one  knows  how  many  cases  there  are  in  which  a  prognostic  forecast  is  impossible,  or 
at  least  mere  guess-work,  and  in  these  a  conflict  begins  between  compulsoiy  classi- 
flcation  and  classification  of  what  may  well  be  considered  as  ready  and  fit.  I  gladly 
acknowledge  my  deep  indebtedness  to  Hoch,  and  later  to  Wernicke,  for  my  gradual 
re-emancipation  from  a  one-sidedness  for  which  I  am  sure  Kraepelin  could  not  have 
been  altogether  accountable.  By  trying  to  fit  every  case,  one  comes  to  a  method  of 
diagnosis  by  exclusion  which  is  not  worthy  of  the  term  of  good  psychiatric  work.  It 
must  be  said,  though,  that  Kraepelin  does  not  warn  us  sufficiently  against  the  ex- 
pedient into  which  one  is  forced  by  an  exaggeration  of  the  importance  of  the  prog- 
nostic element  of  the  disease-concepts.  (The  prognostic  element  has  been  again 
extolled  by  Aschafi"enburg  quite  lately. ) 

The  purest  expression  of  a  traly  psychiatric  use  and  elaboration  of  clinical  princi- 
ples, in  the  sense  of  Kraepehn  at  his  best,  is  undoubtedly  Hoph's,  both  in  his  general 
article  on  the  methods  of  psychiatiy,  and  in  his  monographic  articles  on  mania  and 
on  melancholia.  He  sets  a  splendid  example  for  the  requirement  of  positive  traits 
for  differential  diagnosis  and  for  the  necessity  of  setting  them  forth  in  unmistakable 
observations  of  actual  cases,  and  not  in  vague  generalities.  As  soon  as  this  is  done, 
a  group  of  doubtful  cases  is  created.  The  central  group  of  known  cases  is  kept  clear 
of  admixtures  which  disturb  the  outline  unnecessarily,  and  the  central  group  stands 
f  jr  what  it  is  worth.  In  Kraepelin's  text -book  there  are  only  descriptions  of  groups. 
They  are  very  striking,  but  they  do  not  reach  the  ideal  of  composite  photographs. 
The  descriptions  contain  many  individual  details  which  would  be  submerged  in  a 
composite  photograph.  So  much  is  put  forth  in  one  chapter  that  recurs  in  a  similar 
way  in  another,  that  Wernicke's  criticism  of  haziness  of  distinction  becomes  quite 
justified. 

One  can  not  fail  to  see  in  Kraepehn' s  work  the  slight  stress  placed  on  localization 
of  the  contents  of  consciousness,  excepting  as  far  as  they  are  demonstrative  of  certain 
general  traits.  The  condition  of  the  sensorium  {Besonnenheit) ,  the  coherence  of  the 
stream  of  thought  and  the  forms  of  defect,  the  extent  of  a  plastic  grasp  on  the  situa- 
tion, and  its  actual  utilization,  the  condition  of  acquisitive  and  reproductive  memoiy, 
the  existence  of  odd  and  strained  attitudes  as  compared  to  free  or  inhibited  or  other- 
wise defective  determination  of  activity — these  are  rather  broad  and  biologically 
important  traits  which  always  recur  in  the  differential  diagnosis.  _  A  distinction  into 
auto,  somato-,  and  allopsychic  disorientation  or  delusions,_  etc.,  is  not  attempted  or 
found  necessary.  Analysis  of  types  of  delusions  and  hallucinations  receives  attention 
only  in  the  theoretical  part.     The  symptom-complex  as  such  is  no  longer  interesting 


A  REVIEW  OF  RECENT  PROBLEMS  OF  PSYCHIATRY.  665 

through  its  analysis  as  such,  but  througli  its  position  iu  the  entire  evolution  of  the 
disease.  And  under  this  influence  one's  patience  for  the  analysis  of  symptom-com- 
plexes or  case-records  depends  altogether  on  whether  the  evolution  and  tlie  outcome 
are  properly  reported.  This,  to  my  mind,  is  a  step  in  advance,  bringing  psychiatry 
forward  into  the  line  of  natural  interests  of  the  physician.  We  come  down  to  plain 
questions. 

We  approach  now  a  very  important  point.  Kraepelin  subordinates  the  symptom- 
complex  to  a  broader  clinical,  or  we  might  more  properly  say  to  a  more  simply 
medical  principle — that  of  evolution  and  outcome.  To  what  extent  has  he  created 
"diseases,"  or,  at  least,  to  what  cctent  are  his  diseases  distinct  entities  from  the  point 
of  view  of  pathology  for  pathologi/'s  sake,  not  pathology  with  undue  reference  to 
practical  aims? 

The  fifth  edition  has  much  greater  pretensions  in  this  respect  than  the  sixth. 
In  1896  Kraepelin  practically  recognized  merely  : 

I.  The  group  of  exhaustive  and   infective  origin  (post-febrile  and  collapse 
deliria ;  amentia). 
II.  The  group  of  intoxication  (alcohol,  morphin,  cocain). 

III.  The  processes  of  disorder  of  metabolism  (myxedema,  dementia  praecox, 

general  paralysis). 

IV.  Insanity  due  to  cerebral  disease. 

V.  The  disorders  characteristic  of  the  period  of  involution  (melancholia,  senile 
dementia). 

YI.  Constitutional  disorders  (manic-depressive  insanity,  paranoia,  disorders  ac- 
companying the  neuroses,  idiocy). 

A  number  of  these  categorical  steps  which  I  criticized  in  part  in  my  review  iu 
the  "American  Journal  of  Insanity  "  (Oct.,  1896),  as  undemonstrated  and  too  per- 
emptory claims,  have  been  changed  in  the  sixth  edition.  The  idea  of  diseases  of  meta- 
bolism is  less  prominent  and  the  term  constitutional  psychoses  is  omitted  ;  moreover, 
the  author  found  many  minor  changes  necessary.  In  its  present  shape  the  most  dog- 
matic claims  are  dropped  and  the  whole  is  more  in  keeping  with  the  quotations  from 
Kraepelin  in  an  earlier  part  of  this  chapter.  The  question  whether  these  headings 
are  meant  to  describe  disease-entities  is  no  longer  as  definite  an  issue  as  when 
Kraepelin  first  boldly  made  the  claim  ;  and  we  are  altogether  in  harmony  with  him 
if  we  ask  simply  :  To  what  extent  do  the  groups  approach  the  requisites  of  a  defini- 
tion of  a  disease-entity  ? 

Here  we  meet  first  the  burning  question  :  Is  it  justifiable  to  consider  general  j^'^'^'- 
alysis  the  paradigm  of  mental  disease? 

In  this  question  Wernicke  and  Kraepelin  take  extremely  opposing  views. 
Wernicke  calls  general  paralysis  an  etiological  disease-group.  Trae  to  the  facts,  he 
admits  a  parallelism  between  brain-lesion  and  the  symptoms  of  the  lesions  of  the 
projection-system  and  of  defects  of  the  nature  of  dementia,  whereas  the  great 
variety  of  the  mental  pictures  is  put  down  as  yet  unexplained  and  uncorrelated 
except  by  conclusions  of  analogy.  The  mental  disoi'ders  are  :  (1)  the  expansive 
autopsychosis  (the  megalomania  of  older  writers)  ;  (2)  paralytic  mania  (not  always 
distinguishable  from  pure  mania,  and  frequently  passing  into  the  expansive  auto- 
psychosis, or  at  times  into  a  remission)  ;  (.3)  affective  melancholia  (depression  with 
feeling  of  insufficiency),  rarely  pure,  usually  with  an  admixture  of  delusions  of 
reference  or  with  symptoms  of  an  anxious  psychosis  ;  (4)  depressive  melancholia 
(akinetic,  or  hypokinetic  depression),  also  often  with  admixtures  of  delusions  of 
reference ;  (5)  among  paralytic  allopsychoses  we  meet  frequently  a  paralytic  delirium, 
which  may  occur  at  any  phase  of  the  disease,  and  at  times  resembles  closel.v  a 
delirium  tremens,  but  more  frequently  a  stupor  with  disturbed  sensorium.  Or  the 
presbyophrenic  complex  occurs,  or  a  chronic  hallucinosis,  or  dream-states,  resembling 
epilepsy,  although  but  rarely,  whereas  the  anxious  psycliosis  is  not  infrequently  of 
paralytic  origin  ;  also  hyperkinetic  and  akinetic  motility  psychoses  (akin  to  cata- 
tonia) are  represented. 

On  this  ground  one  may  say  that  general  paralysis  may  show  itself  as  dementia 
after  a  simple  psychosis  ;  but  usually  the  latter  shows  "  paralytic  "  admixtures  from 
the  start  or  passes  into  other  forms  (as  a  mixed  psychosis). 

Nobody  will  deny  the  correctness  of  these  analytical  considerations.  It  does  full 
justice  to  the  absolute  necessity  of  leaving  the  diagnosis  in  suspense  in  a  number  of 
cases  with  indefinite  physical  and  mental  symptoms,  and  to  the  cases  which  seem 
to  favor  the  old  view  that  general  paralysis  may  be  a  complication  of  any  mental 
disorder,  an  occasional  surprise  in  the  course  of  a  paranoia  or  mania  or  stupor,  etc.. 


666  MENTAL  DISEASES. 

examples  of  which  every  alienist  has  certainly  observed,  and  which  should  he  re- 
membered in  the  estimation  of  accuracy  of  a  diagnosis  of  a  simple  psychosis.  It 
also  encourages  a  hope  of  Wernicke's  that  perhaps  it  might  become  possible  to  use 
the  lesions  present  in  general  paralysis,  for  a  determination  of  what  parts  are  affected 
in  definite  types  of  psychoses.  Without  a  veiy  strenuous  effort  to  differentiate  these 
types  of  psychoses,  which  may  be  symptoms  of  irritation  as  well  as  of  defect,  we  can 
not  expect  to  use  the  material  for  a  general  anatomical  explanation  of  mental  dis- 
orders. 

Kraepelin  compares  this  with  a  custom  of  the  past  which  gave  emphasis  to  the 
mental  symptoms  and  qualified  the  accomi^anying  nervous  disorders  as  simple  "com- 
plications."  To  him,  general  paralysis  is  a  progressive  dementia  with  heterogeneous 
nervous  phenomena  of  irritation  and  paralysis,  leading  to  a  complete  annihilation  of 
the  mental  and  physical  personality.  "This  process  is  accompanied  on  the  mental 
side  by  more  or  less  prominent  symjjtoms  of  irritation,  of  excitement,  depression, 
and  by  the  formation  of  delusions  of  greatly  vaiying  content.  The  common  stamp 
in  all  these  derangements  is  a  characteristic  mental  weakness,"  etc. 

Kraeijelin  then  proceeds  to  analyze  the  fundamental  traits — gradual  deteriora- 
tion, disorders  of  sensorium,  exhaustibility,  disorders  of  acquisitive  and  repjroductive 
memory,  especially  for  dates,  poverty  of  the  stream  of  thought,  filling  up  of  gaps  by 
confabulation,  lack  of  judgment  concerning  the  illness,  etc. ,  increased  irritability, 
and  later  duUness,  change  of  character  and  behavior  ;  and,  finally,  he  describes  the 
physical  symptoms  accompanying  the  disorders  of  mentality.  He  gives  up  an 
attempt  to  do  justice  to  the  multiplicity  of  mental  symptom-complexes,  and  merely 
sketches  four  groups — the  depressed,  the  expansive,  the  agitated,  and  the  demented. 

From  practical  and  especially  didactic  points  of  view  such  a  i^reseutation  com- 
mends itself  as  eminently  correct  and  useful  and  much  less  circumstantial  than 
Wernicke's.  One  may  even  go  further,  and  say  that  it  demonsti'ates  lack  of  clinical 
balance  in  those  who  put  so  much  stress  on  formal  traits  of  insanity  as  to  obscure 
the  chief  points  at  issue  for  the  beginner  and  the  practitioner.  One  may  well  say 
that  for  research,  Wernicke's  accurate  standpoint  is  highly  commendable,  and  even 
essential,  but  that,  for  the  needs  of  practice,  the  accentuation  of  the  decisive  fea- 
tures is  what  is  wanted.  This  is  undoubtedly  the  most  important  lesson  taught  by 
the  consideration  of  general  paralysis  and  fully  put  forth  by  Kraepelin.  The  next 
consequence  is  the  question  :  Does  not  the  same  hold  for  all  other  mental  diseases? 
Is  there  not  too  much  energy  spent  on  the  analysis  of  symptom-complexes  from 
fruitless  points  of  view  at  the  expense  of  that  which  interests  practitioners?  Or 
has  the  time  not  come  yet  for  a  radical  change  ? 

The  bold  stroke  of  1896  has  reappeared  in  1899  in  a  decidedly  mitigated  form, 
aud  we  may  well  ask  :  Will  a  future  edition  continue  in  this  relative  retreat  and 
strike  a  level  more  in  harmony  with  the  average  consensus  in  psychiatiy  ? 

Wherein  lies  the  strength  of  Kraepelin' s  position  ? 

The  most  suggestive  and  refreshing  impetus  of  Kraepelin's  departure  does  not 
lie  quite  as  much  in  the  creation  of  pathologically  analyzed  and  unmistakably  under- 
stood types,  but  in  the  spirit  of  emphasis  of  that  which  is  medically  most  important. 
That  impetus  will  never  be  lost  by  one  who  has  ever  been  affected  by  it.  Descrip- 
tions of  symptom- complexes  without  descriptions  of  evolution  _  and  outcome  will 
always  be  unsatisfying,  and  we  crave  for  complete  accounts  of  individual  cases\  But 
the  dogmatism  of  disease-entities  and  of  definite  disease-processes  underlying  all 
their  sj'mptoms  seems  to  meet  a  certain  antagonism. 

Let  us  begin  with  manic-depresswe  insamty,  and  give  Kraepelin  the  field : 

"Manic-depressive  insanity  comprehends,  on  one  hand,  the  entire  domain  of 
so-called  periodic  and  circular  insanity,  and,  on  the  other,  simple  mania  usually  dis- 
tinguished from  the  above.  In  the  course  of  years  I  have  become  more  and  more 
convinced  that  all  the  pictures  mentioned  are  merely  forms  of  one  single  disease- 
process.  It  may  well  be  that  in  the  course  of  time  a  series  of  subtypes  will  be 
made,  or  even  that  certain  small  groups  will  be  again  separated  entirely,  but  if  this 
happens  it  will,  as  far  as  I  can  see,  certainly  not  be  determined  by  those  symptoms 
which  are  now  commonly  put  into  the  foreground.  The  reason  for  my  taking  this 
position  is  the  experience  that  in  all  the  disease-types  mentioned  certain  fundamental 
traits  recur  in  the  same  shape  notwithstanding  manifold  supei-ficial  differences. 
Whoever  knows  the  fundamental  traits  will,  with  due  consideration  to  certain  practi- 
cal difiiculties,  always  be  able  to  conclude  from  a  single  phase  that  it  belongs  to  the 
large  circle  of  forms  included  under  manic-depressive  insanity.  In  this  way  a 
number  of  jjoints  are  gained  for  the  special  clinical  and  prognostic  meaning  of  the 


A  ME  VIEW  OF  RECENT  PllOBLEMS  OF  PSYCHIATRY.  667 

case.  On  the  other  h;iml,  it  is,  us  fur  us  I  can  see,  (juite  impossible  to  find  any 
definite  bounduries  between  tlie  single  disease-pictures  which  have  been  kept  apart 
so  far.  From  'simple'  munia,  the  numerous  cases  with  two,  three,  four  attacks  in  a 
lifetime  lead  over  quite  gradually  to  [periodic  forms,  and  i'rom  these  we  I'each  circular 
insanity,  through  those  cases  in  which  a  more  and  more  marked  initial  or  terminal 
stage  of  deijression  gradually  comi)licutes  the  pure  picture  of  mania,  or  in  which  the 
long  series  of  maniacal  attacks  is  unexpectedly  interrupted  by  a  state  of  depression. 

"There  is  no  alienist,  and,  I  am  convinced,  there  can  not  be  one,  who  would  be 
able  to  recognize  from  the  temj)orary  ])icture  alone  whether  any  case  is  a  simple 
mania,  or  a  periodic  one,  or  circular.  However  different  the  jjicture  of  the  excite- 
ment or  the  depression  may  be  us  such,  it  tells  us  about  as  little  for  the  special 
clinical  interpretation  of  a  case  as,  for  instance,  do  the  various  types  of  paralytic 
excitement  or  depression  for  conclusions  as  to  the  probable  further  course  of 
dementia  paralytica.  There  are,  of  course,  in  either  case,  certain  general  statistical 
rules,  which,  however,  are  very  deceptive  for  the  individual  case,  and  therefore  can 
never  be  of  use  for  the  delimitation  of  real  diseases. 

"  Moreover,  we  not  infrequently  see  in  one  and  the  same  case  the  most  different 
temporary  pictures  tbllow  one  another.  All  the  manifold  types  of  manic  excitement 
m;iy  replace  one  another  in  one  and  the  same  and  in  successive  attacks,  in  simple  as 
well  as  in  periodic  mania,  and  in  circular  insanity.  They  appear  therefore  as 
equioalents,  as  an  expression  of  quite  closely  related  fundamental  conditions  which 
pass  into  one  another  quite  naturally.  In  the  superficially  manifold  arid  temporary 
pictures  of  epileptic  insanity,  dementia  praecox,  and  general  paralysis,  we  always 
turn  to  the  definite  fundamental  disease-process.  There,  all  recognized  pictures  can 
develop  one  after  the  other  in  one  and  the  same  patient.  In  a  similar  way  there  is 
in  manic-depressive  insanity  a  definite  set  of  clinical  types  which  substitute  one 
another,  without  our  being  justified  in  tracing  the  innumerable  varieties  of  form  of 
the  disease-picture  to  essentially  different  fundamental  processes.  On  the  other 
hand,  we  are  quite  in  a  position  to  class  even  the  smallest  fragment  of  the  course  of 
an  attack  which  belongs  here  as  belonging  to  the  large  frame  of  manic-depressive 
insanity.  There  are  no  bridges  leading  over  to  the  other  groups  of  mental  disorders, 
with  the  exception,  perhaps,  of  degenerative  insanity.  ^  For  all  these  reasons  I  am 
led  to  conceive  the  clinical  types  of  manic-depressive  insanity  as  a  unit,  and  to 
represent  the  individual  temporary  pictures  and  types  of  evolution  as  individual 
expressions  of  a  common  disease-process. 

"  Manic-depressive  insanity,  as  its  name  indicates,  takes  its  course  in  single 
attacks,  which  either  present  the  signs  of  so-called  manic  excitement  (flight  of  ideas, 
exaltation,  and  overactivity),  or  those  of  a  peculiar  psychic  depression  with  psycho- 
motor inhibition,  or  a  mixture  of  the  two  states." 

What  actual  help  does  Kraepelin  furnish  us  to  distinguish  his  manic-depressive 
cases  from  the  other  acute  psychoses  ? 

First :  What  are  the  common  signs  of  manic-depressive  equivalents  ? 

Second  :  Which  are  the  most  important  equivalents  ? 

Kraepelin  considers  attention  and  comprehension,  the  sensorium  and  orientation, 
hallucinations  and  delusions,  the  stream  of  thought,  the  mood  and  the  general 
effect  on  the  motor  life,  its  trend,  efficiency,  exhaustibility,  with  special  reference  to 
speech  and  writing — mostly  points  which  are  open  to  comparison  with  experimental 
material  and  in  many  respects  open  to  test-experiment  with  the  patient.  It  is 
hardly  necessary  to  give  more  than  a  meager  summary,  since  an  abstract  is  available 
in  English. 

Attention  and  comprehension  suffer  in  all  but  the  slightest  cases.  In  excited 
phases  it  is  chiefly  an  extraordinary  distractibility  and  insufficient  grasp  and  elabora- 
tion of  the  rush  of  impressions,  showing  in  overexcitability  in  some  directions  and 
insensitiveness  in  others  (exposure).  In  depression,  distractibility  may  persist,  but 
the  trouble  with  the  elaboration  and  comprehension  of  impressions  is  much  more 
prominent. 

The  sensorium  is  always  slightly  affected  in  severer  cases.  This  shows  in  slight 
disturbance  of  orientation,  especially  concerning  persons  ;  in  depressions  and  stupor 

^Which,  according  to  vol.  ii,  p.  529,  includes  the  general  neuroses,  manic-depres- 
sive insanity,  certain  forms  of  imbecility,  and  perhaps  also  paranoia  ;  like  all  the 
products  of  the  theory  of  "degeneration,"  an  etiologically  rather  vague  conglomera- 
tion in  which  constitutional  peculiarities  play  the  important  role,  whether  truly 
"  degenerative  "  or  not. 


668  JIEXTAL  DISEASES. 

tlie  disturbauce  is  especially  ajjt  tu  be  pronounced,  even  tu  the  deiith  of  a  lasting 
dream-state. 

Hallucinations  are  not  infrequent,  usually  of  tbe  nature  of  illusions,  or  actual,  as 
especially  in  the  depressive  and  stuporous  phases.  Delusions  are  very  changeable. 
but  sometimes  they  are  held  and  elaborated  (ideas  of  grandeur,  persecution,  jealousy, 
fear  of  poisoning).  In  depressions  there  occur  especiaUy  ideas  of  sinfalness.  of 
persecution,  and  of  hypochondriacal  nature.  Their  frequently  fantastic  nature, 
reminding  one  of  general  paralysis  or  senility  (especially  the  hypochondriacal  ideas), 
is  held  up  as  e\'idence  of  the  view  that  neither  the  content  ol'  delusions  nor  their 
mere  occurrence  allows  of  any  conclusions  concerning  the  nature  of  the  disease- 
process.  A  certain  insight  into  the  disease  is  usually  present,  but  excitement  or 
depression  is  usuahy  referred  to  personal  or  external  causes. 

The  stream  of  thought  shows  the  most  characteristic  disorders.  Mere  habit  and 
the  greater  ease  in  yielding  to  momentaiy  impulses  get  the  better  of  what  would  be 
demanded  by  actual  circumspection  and  aim  ;  and  a  flight  of  ideas  is  the  result. 
There  is  no  far-sighted  leading  purpose  ;  the  resulting  incoherence  is,  however,  not 
lawless.  The  unrestrained  yielding  to  aU  sorts  of  im^jressions  and  whims  even 
creates  the  appearance  of  increased  quickness  of  perception.  In  depressions  the 
patients  may  actually  complain  of  all  kinds  of  thoughts  passing  through  their  heads 
and  of  the  resulting  confusion  ;  there  is,  moreover,  difl&culty  in  disposing  of  the 
thoughts,  and  usually  an  actual  inhibition  of  thought,  so  that  the  patient  may 
appear  very  hmited  and  even  demented.  Even  in  the  excited  phases  the  " '  accelera- 
tion ' '_  of  ideation  really  only  covers  up  the  slowness  of  association  owing  to  the 
flightiness  and  instability  of  the  links  of  the  trend  of  thought. 

The  mood  is  a  decided  feature ;  exaltation  or  imtability,  or  tnie  depression,  and 
not  infrequently  a  mixture  of  these  traits. 

The  most  striking  disorders  belong  to  the  psychomotor  sphere.  The  patient  is  all 
activity,  yields  irresistibly  to  every  impulse  ;  but  in  distinction  from  other  forms  of 
motor  restlessness,  manic  restlessness  can  almost  always  be  traced  to  some  moods  or 
purposes,  playfulness,  etc.  The  condition  is  easily  exaggerated,  and  the  ready  incita- 
bility  is  perhaps  the  fundamental  trait,  together  with  insensitiveness  to  fatigue.  The 
part  played  by  speech,  the  tendency  to  drift  in  the  direction  of  aUiterations  and 
rhymes,  is  especialljMmportant  owing  to  its  influence  on  the  flight  of  topics  in  which 
connection  and  leading  thought  are  lost.  In  the  writing,  too,  the  trivial  signs  of 
activity  get  the  better  of  legibility  and  sense. 

In  depressions  the  very  opposite  occurs  in  the  form  of  psychomotor  inhibition. 
Indecision,  difiieulty  or  inability  to  make  up  one's  mind,  show  especially  in  expres- 
sions, speech  ;  and  the  mere  hesitation  at  the  start  leads  over  to  hesitation  and  slow- 
nessand  weakness  in  the  execution.  External  stimulation  or  danger  may  overcome 
the  inhibition ;  but  in  deep  depression  or  stupor  even  these  may  faU. 

Inhibition  and  facilitation  of  voluntary  impulses  are,  however,  hardly  as  great 
contrasts  as  would  seem  at  first  sight.  They  are  so  apt  to  pass  abruptly  into  one 
another,  and  so  often  they  occur  in  a  peculiar  mixture,  that  the  characteristic  vari- 
ability of  the  voluntary  responses  is,  after  all,  one  of  the  fundamental  traits  of  this 
entire  disease-group. 

For  didactic  and  practical  purposes,  Kraepehn  classifies  the  material  of  pertinent 
observations  into  three  main  groups — the  preeminently  manic,  the  preeminently 
depressed,  and  the  mixed  states. 

He  gives  excellent  pictures  of  the  slightest  forms  of  excitement  (hypomania).  of 
severer  forms  (mania),  and  the  forms  with  transitoiy  or  lasting  confusion  and  greater 
prominence  of  hallucinatory  and  delusional  productivity — all  with  characteristic  moods 
and  flight.  Finally  he  gives  a  picture  of  the  usually  much  shorter  deliriovs  attacks. 
of  a  little  over  three  or  four  weeks'  duration,  with  a  veiy  rapid  development  of  a  deep 
dream-like  clouding  of  consciousness,  complete  disorientation  with  numerous  hallu- 
cinations and  confused  delusions  of  greatly  varying  color,  so  that  the  patient  drifts 
rapidly  from  fear  and  anxiety  to  elation  and  ecstasy,  or  into  dull  indifi"erence.  Sen.se- 
less  motor  excitement,  beyond  the  ])ossibility  of  fixation  of  attention,  extreme  flight  of 
ideas  and  dLstractibility,  vary  with  times  of  confused  dullness  :  there  is  no  sleep  : 
rapid  decay  ;  frequently  tremor  of  the  whole  body  and  lively  reflexes.  Remnants  of 
delusions  and  anomalous  mood  may  outlast  the  excitement  and  confusion,  and  diffi- 
dence, irritability,  and  perhaps  also  slight  flight  of  ideas  may  persist  for  several 
weeks.  Usually  the  events  of  the  psychosis  are  forgotten  completely-  The  duration 
of  the  manic  forms  is  longer,  usually  months,  not  infrequently  two  or  three  years, 
especially  when  there  are  manifold  delusions  and  only  moderate  transitory  exacerba- 


A  REVIEW  OF  RECENT  PROBLEMS  OF  PSYCHIATRY.  669 

tioiis  of  excitement.  The  termination  is  frequently  a  slight  depression  before  com- 
])lete  recovery  takes  place.  After  severe  attacks  in  some  cases  it  seems  that  a  certain 
lack  of  judgment,  lack  of  insight  into  the  disease,  irritability,  and  moodiness  may  be  a 
permanent  residual. 

The  depressive  attacks  show  similar  degrees.  A  feeling  of  difficulty  of  concen- 
tration and  thought,  subjective  insufficiency  and  dullness,  a  hopeless  attitude,  lack  of 
interest  and  fear  of  the  future,  occasionally  imperative  trains  of  thought  (a  symptom 
common  to  types  of  degenerative  insanity),  indecision,  and  inactivity  mark  the  lighter 
cases.  Some  cases  may  pass  into  a  real  stupor  in  which  the  patient  grasps  nothing, 
shows  hardly  any  affect  except  perhaps  slight  perplexity,  and  a  few  attacks  of  anxious 
self-defense.  Catalepsy  and  aboulia,  or  planless  resistance,  may  be  met  with.  The 
memory  of  the  attack  is  very  hazj'. 

In  a  second  large  group  delusions,  especially  of  sinfulness  and  persecution,  are 
superadded  to  the  disorder  of  thought  and  psychomotor  inhibition,  and  also  occasional 
hallucinations  of  sight,  hearing,  etc.  Or  hallucinations  and  delusions  of  persecution 
may  set  in,  as  in  alcoholic  hallucinosis,  with  perfectly  clear  sensorium,  and  complete 
orientation  ;  there  is,  however,  a  certain  monotony  in  the  complaints  and  a  rather 
rapid  giving  out  in  thinking,  speaking,  or  writing  ;  the  mood  is  one  of  discourage- 
ment, or  of  dull  staring,  or  of  despair  with  monotonous  wailing.  Usually  a  certain 
psychomotor  inhibition  is  demonstrable.  In  other  cases  a  deep  stuporous  cloudiness 
of  consciousness  may  appear ;  over  the  disconnected  but  greatly  varied  and  often 
absurd  deliria  and  hallucinations,  the  patient  becomes  inaccessible,  mute,  only  showing 
the  strange  mental  state  by  a  tense  anxious  expression  and  resistance  against  influ- 
ences, or  by  casual  odd  attitudes  or  motions,  or  by  an  occasional  suicidal  impulse  ; 
or  at  times  they  produce  fragmentary  utterances.  Some  of  the  illusions  may  persist 
during  convalescence. 

The  third  ''' mixed '^  ^i/P^  is  theoretically  and  practically  very  important,  and  its 
description  by  the  Heidelberg  school  a  most  creditable  achievement.  Kraepelin 
refers  here  to  those  unaccountable  changes  from  exaltation  to  depression  and  vice 
versa,  and  to  the  actual  mixture  of  simultaneous  manic  and  depressive  symptoms, 
which  are  either  transitory  (jokes  or  other  signs  of  exhilaration,  or  of  facilitation 
of  voluntary  reactions  in  the  midst  of  a  depression,  or  depressive  and  anxious 
moods  in  the  manic)  or  persistent,  as,  for  instance,  the  cases  in  whom  the  manic 
symptoms  coexist  with  inhibition  or  depression  with  excitement  throughout  the 
greater  part  of  an  attack.  He  describes  forms  of  exaltation  with  decided  dearth  of 
ideas,  slow  and  inaccurate  attention  with  times  of  very  inadequate  response.  With 
it  all  the  patient  is  cheerful,  laughs,  is  excitable,  makes  fun  ;  but  the  restless  activ- 
ity is  limited  to  a  few  pranks  or  occasional  outbreaks.  In  extreme  cases  the 
patient  appears  almost  stuporous  (hence  the  term  "manic  stupor").  Other  cases 
are  exalted,  but  mainly  fault-finding  and  irritable.  These  conditions  are  not  infre- 
quent during  the  transition  from  manic  to  depressive  states. 

In  other  cases  depression  is  accompanied  by  a  veritable  flight  of  ideas  in  the  ex- 
pression of  delusions  of  sinfulness  and  despair  ;  or  the  patients  merely  speak  later 
of  the  rush  of  ideas.  These  episodes  occur  at  times  in  the  transition  from  de- 
pression to  mania. 

If  we  add  to  this,  that  the  physical  condition  shows  certain  definite  relations  to 
the  mental  disorder,  that  cause  and  nature  appear  to  be  mainly  constitutional,  that 
the  course  is  episodic  and  only  in  4  or  5  per  cent,  consisting  of  continuous  circles, 
and  that  only  in  few  cases  slight  residuals  develop  (only  the  short  attacks  which 
recur  very  often  seem  to  tend  to  a  certain  deterioration) — we  have  a  fair  summary  of 
the  group. 

After  his  description  of  the  forms,  Kraepelin  resumes  the  discussion.  He  points 
out  the  great  variability  and  relative  triviality  of  the  caiise  of  single  attacks,  and  the 
often  surprising  independence  of  the  whole  group  from  external  influence,  and  in- 
sists on  the  constitutional  feature  in  their  etiology. 

Kraepelin's  argument  appears  very  convincing,  unless  there  should  be  too  many 
transition  cases  to  the  group  of  dementia  praecox.  There  also  may  be  a  question  as 
to  whether  the  periodic  mental  disorders  are  really  all  manic-depressive.  It  cer- 
tainly demolishes,  effectively  in  the  eyes  of  an  impartial  alienist,  the  old  dogma 
concerning  certain  traditional  distinctions,  and  pushes  to  the  front  matters  of  greater 
medical  interest. 

We  must  now  take  up  another  large  group  of  Kraepelin's,  that  of  dementia 
prcecox.  As  will  be  remembered  from  the  quotation  heretofore  cited,  it  is  a  pro- 
visional group,  originally  described  as  a  disease  of  metabolism,  together  with  myx- 


670  MENTAL  DISEASES. 

edema  and  general  paralysis.  Referring  to  our  previous  remarks,  we  recapitulate 
Kraepelin's  belief  of  1896.  He  realizes  (fifth  edition,  p.  414)  that  he  goes 
beyond  the  facts  established  by  research  by  assuming  that  in  all  these  diseases  the 
cortex  is  damaged  by  poisons  produced  by  a  morbid  constitution  of  the  fluid  parts 
of  the  body  owing  to  the  derangement  of  certain  organs  which  have  a  special  influ- 
ence on  metabolism.  "This  conception  proved,  however,  so  fruitful  in  myxedema 
and  cretinism  that  its  further  application  is  warranted  on  the  mere  fact  that  the 
clinical  coincidence  with  these  forms  is  veiy  obvious  in  the  chief  characteristics." 

This  assumption  has  been  dropped  for  lack  of  sufiicieut  evidence,  ^  and  the  term 
"  processes  of  deterioration  "  is  abandoned  because  deterioration  is  the  key-note  of 
general  paralysis  and  of  senile  dementia  as  well,  and  they  might  be  understood  as  in- 
cluded under  that  term.  We  shall  also  see  that  Kraepelin  acquiesces  in  the  generally 
accepted  distrust  of  prognostic  principles  at  least  in  melancholia  (which  is  a  disease 
of  variable  prognosis,  and  therefore  a  difi"erent  sort  of  an  entity  from  Kraepelin's 
other  disease  types,  one  not  consistently  created  from  the  prognostic  standpoint);  and 
we  may  well  be  anxious  to  learn  why  deterioration  should  be  considered  the  chief 
characteristic  of  a  special  group.  Is  it  a  deterioration  such  as  would  never  result 
from  a  disease  like  melancholia,  or  any  other  ' '  simple  ' '  disorder  ?  When  defining 
dementia  prsecox  as  a  "series  of  disease-pictures,  the  common  feature  of  which  is 
the  termination  in  a  special  kind  of  state  of  mental  weakness,"  Kraepelin  adds  : 
"  It  seems,  however,  that  this  unfavorable  termination  need  not  take  place  without 
exception,  but  it  is  so  uncommonly  frequent  that  for  the  present  we  still  prefer  to 
maintain  the  term  in  use.  Perhaps  other  terms,  such  as  that  oi'  deinenza  primifiva 
of  the  Italians,  or  dementia  simplex  (preferred  by  Rieger),  are  even  more  appropriate. 
According  to  the  clinical  and  anatomical  facts  known  so  far,  I  cannot  doubt  but  that 
we  deal  here  with  severe  damage  to  the  cortex,  as  a  rule  but  partially  recoverable 
at  best.  Whether  the  disease-process  is  the  same  throughout  must  be  left  in 
uncertainty  at  the  present  time. ' '  Further  :  ' '  The  variability  of  temporary  pictures 
(symptom-complexes)  which  we  observe  in  the  course  of  dementia  praecox  is  veiy 
large,  so  that,  on  superficial  observation,  the  inner  connection  can  often  be  recognized 
only  with  great  difficulty.  We  find,  however,  certain  fundamental  derangements 
over  and  over  again  in  a  more  or  less  explicit  form  ;  most  purely,  it  is  tnie,  in  the 
terminal  states  in  which  the  more  or  less  accidental  and  transitory  accessoiy  symptoms 
of  the  disease-process  have  receded  behind  the  lasting  and  characteristic  changes  of 
the  mental  life. ' ' 

This  elevation  of  the  ' '  outcome  "  to  a  nosological  criterion  is  a  very  radical  step. 
A  priori,  many  objections  on  general  medical  principles  revolt  against  it.  But  all 
objections  will  fail  if  the  empirical  result  is  in  harmony  with  the  claim.  In  an  em- 
pirical science  we  ar.e  far  less  concerned  about  the  reason  of  the  fact  than  about  its 
certainty,  and  the  possibility  of  predicting  it  from  conditions  which  do  not  already 
include  it,  or  include  it  so  that  it  was  not  formerly  recognized. 

In  Kraepelin's  book,  we  look  in  vain  for  the  term  secondary  or  terminal  dementia. 
Since  the  collapse-delirium  and  the  (rare)  amentia  (which  comprehends  only  J  per 
cent,  of  Kraepelin's  cases)  do  not  leave  behind  dementia,  since  the  toxic  psychoses 
are  a  topic  by  themselves,  and  of  relatively  good  prognosis,  and  epilepsy  and  senility 
are  anyhow  distinct  entities;  moreover  since  manic-depressive  insanity  has  one  of  its 
fundamental  raisons  d'etre  in  the  exemption  from  deterioration — we  must  see  in  the 
cases  of  dementia  praecox  the  almost  exclusive  ground  for  the  development  of 
' '  secondary  dementia. ' ' 

Let  us  see  what  Kraepelin's  distinctions  are  : 

In  manic-depressive  insanity  we  found  our  diagnosis  on  a  triad  of  symptom-pairs — 
exaltation  and  depression  of  feelings  (as  we  have  learned  from  Wernicke  ;  not  to  be 
mixed  up  loosely  with  perplexity),  flight  of  ideas  or  inhibition  of  thought,  and  irre- 
sistible psychomotor  unrest  or  inhibition.  These  fundamental  symptoms  decide  the 
diagnosis,  and  our  final  question  will  be  :  Are  they  traits  of  constitution  and  tem- 
porary exaggeration  of  individual  make-up,  or  are  they  the  expression  of  a  special 
disease  ?  To  what  extent  are  they  at  the  core  of  the  pathological  process,  and  to 
what  extent  collateral  evidence  or  individual  response  ?  Do  they  explain  the  ten- 
dency to  recurrence  and  the  absence  of  deterioration  in  these  types  ? 

And  what  are  the  fundamental  traits  claimed  for  dementia  prcecox  apart  from 
termination  in  a  peculiar  kind  of  mental  weakness? 

^  And  to  those  who  do  not  live  in  goiter  regions  it  must  be  especially  welcome  to 
see  a  paradigm  withdrawn  with  which  they  liave  only  theoretical  experience. 


A  BE  VIEW  OF  RECENT  PB0BLE5IS  OF  PSYCHIATRY.  671 

Kraepelin's  description  is  not  very  direct.  It  follows  his  general  plan  of  examina- 
tion, which  makes  a  dissection  of  one's  experience  with  the  patients,  which  may  be 
distracting  for  one  not  hardened  and  trained  to  it. 

The  comprehension  of  external  stimuli  is  usually  not  deeply  interfered  with  ;  the 
patients  often  have  a  remarkably  good  understanding  of  what  is  going  on  even  dur- 
ing great  excitement,  and  their  orientation  as  to  place,  person,  and  dates  is  usually 
surprisingly  intact,  except  occasionally  in  stupor  and  profound  anxiety.  The  correct 
perception  is,  however,  at  times  concealed  by  delusional  interpretations,  and  espe- 
cially obscured  by  the  frequent  disinclination  to  give  an  account  and  the  tendency  to 
trifling  or  to  intentional  deception.  Hallucinations  hardly  ever  are  missed  in  an 
acute  or  a  subacute  development  of  the  disease.  They  either  persist  or  fade  slowly  ; 
at  first  they  are  usually  unpleasant,  and  later  they  are  taken  with  indiflPerence.  Those 
of  hearing  are  most  prominent,  next  those  of  vision  and  touch  and  sensations  of 
currents  of  contacts  and  of  various  influences.  They  are  frequently  looked  upon  as 
artificial,  as  a  kind  of  theater,  sometimes  amusing  ;  it  is  usually  difiicult  to  get  de- 
scriptions. Often  they  are  absurd  and  incoherent,  even  when  the  patient  is  con- 
nected. 

The  sensorium  or  consciousness  is  perfectly  and  permanently  clear  in  many  cases. 
Temporary  cloudiness  in  excitement  and  stupor  is  usually  slight  and  often  only  ap- 
parent. Attention,  on  the  other  hand,  is  always  deeply  afi'ected,  owing  to  great  dis- 
tractibility,  and,  above  all,  owing  to  a  lack  of  spontaneous  interest,  a  lack  of  real 
desire  to  digest  and  understand.  In  deep  stupor  or  advanced  dementia  it  may  be- 
come quite  impossible  to  rouse  any  attention  ;  on  the  other  hand,  there  may  be  a 
stealthy  curiosity,  breaking  at  times  through  the  negativism. 

3Iemory  is  relatively  little  disturbed,  surprisingly  so  ^oy  fragmentary  knowledge 
of  dates,  school-information,  etc.  Also  the  acquisition  of  new  numbers  or  names 
by  apparently  totally  apathetic  patients  and  their  retention  for  days  and  weeks  is 
sometimes  surprising.  But  it  is  frequently  difficult  to  get  at  the  facts  owing  to 
negativism. 

The  course  of  thought  always  suffers  profoundly  sooner  or  later.  Even  apart 
from  the  incoherence  in  states  of  excitement  and  from  stupor,  there  is,  as  a  i-ule, 
an  increasing  dilapidation  of  thouglit.  At  first  it  may  show  merely  in  increased  dis- 
tractibility,  sudden,  erratic,  often  senseless  changes  of  topic,  and  in  the  interpolation 
of  supei-fluous  phrases  and  digressions.  This  not  infrequently  culminates  in  a  con- 
fusion of  speech  with  a  loss  of  all  connection  and  with  new  words,  often  in  striking 
contrast  to  the  connected  behavior  and  the  real  train  of  thought,  in  which  the 
patient  may  grasp  and  even  elaborate  in  good  order,  although  even  in  this  respect 
signs  of  stereotypy,  clinging  to  single  concepts,  and  the  recurrence  of  the  same  lim- 
ited phrases  for  weeks  or  months,  show  a  reduction.  Frequently  there  is  also  a 
tendency  to  rhymes,  to  senseless  repetitions  of  sounds,  to  forced  word-plays. 

Without  exception,  there  is  also  a  profound  damage  to  judgment.  With  all  the 
retention  of  old  knowledge  and,  in  some  ways,  of  its  use,  the  defect  of  attention 
does  not  fail  to  prevent  a  real  grasp  on  the  situation  ;  the  most  natural  conclusions 
fail  to  be  drawn  ;  discrepancies  and  objections  are  not  thought  of.  Hence  the 
erroneous  views  on  their  situation  and  condition,  the  inability  to  grasp  the  serious- 
ness of  the  disorder  and  of  its  consequences. 

Extremely  often  transitory  or  lasting  delusions  form  on  this  ground,  at  first  sad, 
hypochondriacal,  self-accusatory,  or  persecutorj%  later  more  expansive,  but  mostly 
contrary  to  all  sense  or  at  least  more  or  less  erratic  and  somewhat  changeable.  Even 
in  the  clearly  paranoia-like  forms  the  delusions  gradually  lose  their  force  and  connec- 
tion, while  in  the  other  forms  they  finally  reappear  only  from  time  to  time. 

Very  striking  and  profound  disorders  regularly  take  place  in  the  emotional  life. 
The  sadness,  anxiety,  or  excitement  of  the  onset  or  the  rarer  gaiety  with  immod- 
erate laughter  pass  into  more  or  less  emotional  dullness.  This  is  perhaps  at  the 
root  of  the  general  indifi"erence  of  attention,  and  not  infrequently  the  first  sign  for 
parents  and  friends ;  matters  of  interest,  ties  of  aff"ection,  even  wonted  pleasure 
(except  perhaps  the  attractions  of  food),  are  neglected  ;  and  occasional  irritability 
shows.  The  demeanor  and  activity  seem  to  show  a  general  reduction  of  voluntary 
impulses  in  general,  quite  plainly  in  the  terminal  stages,  but  often  at  the  outset. 
The  patient  becomes  lazy  and  neglectful ;  if  excitement  occurs  it  lacks  definite 
aims,  and  is  a  planless  discharge  of  inner  tension.  It  is  often  an  impulsive  reaction 
to  a  sudden  whim,  without  explanatory  reasons,  or  at  least  no  convincing  ones. 

The  same  inadequacy  of  control  shows  also  in  stupor,  which  is  generally  governed 
by  the  phenomenon  of  obstruction  of  will,  a  wiping  out  of  every  impulse  by  a 


672  MENTAL  DISEASES. 

stronger  one  in  the  opposite  direction  ;  this  is  especially  manifest  as  negativism 
which  is  shown  in  resistance,  aversion,  direct  perversion,  or  mere  inaccessibilitj'. 
Even  in  this  stage  sudden  senseless  outbreaks  are  observed,  perhaps  fjllowed  as  sud- 
denly by  a  relapse  into  stupor.  Not  infrequently  the  same  impulse  reappears, 
stereotypies  of  motion  and  attitude  develop,  so  characteristic  of  catatonia,  also 
verbigeration,  mannerisms  and  oddities  in  many  ordinary  actions,  which  may  persist 
for  years. 

Probably  in  some  connection  with  severe  damage  to  the  will  and  to  spontaneity, 
we  farther  JBnd  automatic  responses  to  suggestion.  The  patients  become  members  of 
a  herd,  and  in  many  of  them  there  is  temporary  or  permanent  catalepsy,  and  often 
echolalia  and  echopraxia.  Although  these  symptoms  vary  considerably  there  are 
probably  few  cases  of  dementia  praecox  who  would  not  present  the  one  or  the  other 
of  these  signs  at  some  period  of  the  course  of  the  disease. 

The  capacity  for  work  suffers  very  considerably  without  exception._  The  patient 
needs  urging  everywhere  and  is  incapable  of  adaptation  to  new  conditions.  _  Work 
of  a  monotonous  kind  is  often  done  faultlessly,  but  also  thoughtlessly  or  with  odd 
admixtures. 

The  physical  condition  is  equally  marked.  Fainting  spells  and  epileptiform 
convulsions,  more  rarely  spasms  of  isolated  muscle-groups  (face,  arm),  tetany,  or 
apoplectiform  attacks  and  even  prolonged  palsy  are  noted  as  preceding  the  disease. 
At  times  such  an  attack  of  coma  is  the  beginning.  Ki-aepelin  noted _  such 
incidents  in  18  per  cent,  of  his  cases,  excluding  those  cases  of  spasms  or  fainting 
spells  in  childhood  the  bearing  of  which  is  quite  uncertain.  Moreover,  therewere 
in  several  instances  hysteriform  spasms  and  palsies,  aphonia,  singultus,  sudden  rigidity, 
local  contractures,  etc. ,  and  lasting  peculiar  choreatic  motions  (athetoid  ataxia).  In 
two  cases  there  were  plain  aphasic  disorders  during  a  state  of  duU  cloudiness  (inabil- 
ity to  recognize  and  name  objects  for  several  hours  although  the  patients  could 
speak  and  made  evident  efforts). 

The  tendon  reflexes  are  always  increased,  also  frequently  the  mechanical  irrita- 
bility of  muscles  and  nerves  ;  the  pupils  are  often  wide  or  different ;  vasomotor 
disorders,  cyanosis,  circumscribed  edema,  dermatographia,  and  at  times  excessive 
perspiration  are  found.  Saliva  is  often  abundant.  The  heart's  action  is  subject  to 
great  variation  and  is  often  weak  and  irregular.  The  temperature  is  usually  low, 
the  menses  irregular  or  absent.  The  obsei'vations  of  disorder  of  the  thyroid  have 
probably  only  local  interest.  Anemia  is  very  frequent.  Once  there  was  glycosuria, 
once  polyuria.  Sleep  is  much  deranged  ;  the  appetite  often  perverse.  The  weight 
is  very  irregular,  and  is  apt  to  rise  finally. 

Since  the  forms  are  very  variable,  a  division  into  hebephrenic,  catatonic,  and 
paranoic  forms  is  artificial  and  claims  only  didactic  value.  For  a  special  descrip- 
tion we  must  refer  to  the  text.  For  our  present  purposes  it  may  be  sufficient  to 
state  that  the  paranoid  forms  are  given  the  poorest  prognosis ;  the  hebephrenic 
forms  show  in  75  per  cent,  a  profound  dementia,  in  17  per  cent,  a  moderate  de- 
mentia, and  in  8  per  cent,  what  might  practically  be  called  a  recovery.  Catatonia 
results  in  59  per  cent,  in  a  peculiar  and  considerable  dementia  ;  in  27  per  cent,  the 
dementia  is  moderate  or  slight,  and  in  1 3  per  cent,  there  are  no  residuals  or  but 
slight  ones.  A  certain  number  of  these  are,  however,  likely  to  experience  fatal 
relapses.  Twenty  per  cent,  of  the  patients  show  prolonged  remissions  resembling 
recoveries  and  lasting  up  to  "five  to  ten  years."  The  remarks  on  the  reasons  for 
the  difference  of  prognosis  (vol.  ll,  p.  180)  are  of  decided  importance  to  us. 

"To  my  regret  I  have  not  been  able  so  far  to  find  any  definite  points  from 
which  to  draw  conclusions  concerning  the  probable  termination  of  the  individual 
case.  Considering  the  recoveries,  as  it  were,  as  remissions  of  long  duration,  we 
should  have  to  answer  the  question  :  Which  cases  justify  hopes  for  the 
occurrence  of  prolonged  remissions,  and  after  how  long  a  time  may  we  still 
hope  for  one  ?  There  is  no  doubt  but  that  in  general  the  attacks  of  rapid  onset  are 
more  likely  to  lead  to  remissions  than  the  slowly  developing  ones,  veiy  much  as 
in  general  paralysis.  Since  an  acute  onset  with  vivid  excitement  is  incomparably 
more  frequent  in  catatonia  than  in  the  hebephrenic  forms,  we  may  well  make  this 
accountable  for  their  more  favorable  prognosis.  Moreover,  the  probability  of  con- 
siderable improvement  becomes  less  in  a  measure  as  those  pecuHarities  develop 
which  we  find  so  prominent  in  the  large  number  of  certainly  incurable  cases.  We 
mention  the  loss  of  emotional  responsiveness  while  comprehension  is  preserved  ; 
further,  the  fixed  mannerisms  and  stereotypies,  and  finally  the  periodic  unaccount- 
able depressions  and  excitements.     It  is  naturally  merely  a  supposition  so  far,  that 


A  REVIEW  OF  EECEXT  PR0BLE3IS  OF  PSYCHIATRY.  673 

the  development  of  these  and  probably  of  many  other  signs  means  the  approach  of 
an  incurable  terminal  state,  yet  many  experiences  are  in  favor  of  this.  A  very 
large  number  of  observations,  caretuUy  planned  and  continued  with  this  in  view,  will 
gradually  make  this  matter  clear. 

■ '  It  is,  of  c(jurse,  nut  always  easy  to  be  quite  sure  concerning  the  existence  of 
thuse  signs.  Iiidiflereuce  toward  the  happenings  in  the  surroundings  may  also  be 
pretended,  through  negativism  or  through  stupor.  Only  when  the  patients  show 
absolutely  no  interest  in  their  fellow-patients,  their  relatives  and  their  occupation, 
nutwithstaiiding  complete  composure  and  without  the  signs  of  negativism,  may  we 
conclude  that  the  emotional  responsiveness  is  actually  annihilated.  In  a  similar 
way,  only  the  tmly  lasting  and  completely  fixed  stereotypies  can  be  used  to  judge  of 
the  chances  of  recovery,  and  only  those  depressions  and  excitements  which 
enlarge  and  disappear  again  suddenly  after  quite  a  short  duration  and  at  more 
or  less  reg-ular  intervals.  On  the  other  hand,  the  persistence  of  a  decided  negativ- 
ism with  stupor  would  seem  to  be  open  to  far-reaching  improvement  even  after  a 
very  long  time.  In  definitely  incurable  cases  the  negativism  usually  subsides  grad- 
ually ;  yet  we  know  cases  in  which  a  negativistic  stupor  terminated  in  a  surprising 
recovery  with  defect  after  three,  five,  and  even  eight  years.  Whether  siich  cases 
im]>ly  probabilities  or  merely  remote  possibilities  requires  further  investigation." 

These  passages  should  be  sufficient  to  show  the  reader  the  caution  of  Kraepelin 
and  the  restriction  which  he  put  upon  himself,  and  also  the  points  which  he  isled 
to  consider  most  fundamental  for  the  working  of  the  disease-principle  which  brings 
about  the  various  results. 

The  last  group  created  by  Kraepelin  and  to  be  drawn  into  the  scopeof  our  in- 
vestigation is  that  of  melandiolla.  By  this  term  are  meant  all  the  morbid  anxious 
depressions  of  advanced  age  such  as  do  not  represent  phases  of  other  forms  of  in- 
sanity. Besides  depression,  there  are  always  delusion  formations,  especially  of  sin- 
fulness, but  also  of  persecution  and  hypochondriasis.  The  onset  is  gradual ;  the 
])atient  feels  poorly,  is  anxious  and  dull,  worries,  but  has  good  and  bad  days.  All 
doubtfiil  actions  ever  done  assume  immense  proportions ;  against  the  remorse  no 
reasoning  avails,  and  the  ideas  seem  to  be  more  than  explanations  for  the  depression. 
Fear  of  punishment  and  of  the  consequences  of  thoughts  and  actions  add  farther 
elaborations.  Hypochondriacal  ideas  of  effects  of  ill-practices  or  interpretations  of 
temporaiy  sensations  are  fantastically  worked  out.  Isolated  hallucinations,  scolding, 
or  -suggesting  things,  or  visions  of  all  sorts  of  absurd  things,  add  to  the  torment, 
Sensorium  and  orientation  remain  clear,  notwithstanding  the  occasional  delusional 
statements  that  things  and  people  are  ' '  difierent ' ' ;  the  stream  of  thought  is  coherent 
though  somewhat  monotonous,  although  the  patient  may  complain  of  "so  many 
thoughts. 

A  second  group,  of  usually  older  patients,  may  be  made  of  those  cases  who  have 
more  prominent  erratic  and  absurd  delusions  and  elaborations  of  what  they  see  and 
feel;  forms  of  "'depressiver  Wahnsinyi."  Nihilistic  ideas  may  govern  the  field,  or 
at  times  meager  delusions  of  an  exalted  character;  hallucinations  are  more  marked  ; 
the  sensorium  and  orientation  are  frequently  less  clear.  The  stream  of  thought  is 
confused  and  monotonous,  especially  during  agitation  ;  invariably  anxiety  is  asso- 
ciated with  the  depression  ;  but  there  is  a  certain  absorption  restricting  the  scope  of 
interest.  Relatives  are  apt  to  make  a  deeper  impression  on  them  than  even  very 
excited  fellow-patients.  Concerning  their  attitude,  there  are  all  grades  of  transitions 
of  agitation.  The  course  of  the  disease  always  shows  a  more  or  less  regular  cuitc. 
The  prognosis  is,  on  the  whole,  doubtful.  Only  32  per  cent,  recovered,  2-3  per  cent, 
improved  enough  to  go  home  and  partially  resume  their  occupation,  26  per  cent,  re- 
mained uncured,  and"l9  per  cent,  died  during  the  first  two  years.  Among  the  cases 
below  fifty-five  years  oiF  age,  40  per  cent,  recovered  ;  of  the  older  ones,  only  25  per 
cent.  The  unfavorable  turn  usually  shows  in  a  decrease  of  emotional  excitement 
without  a  decrease  of  "the  morbid  concepts,  or  with  a  development  of  absurd  delu- 
sions. When  depression  and  delusions  finally  fade,  the  patient  reruaius  dull  and  in- 
different, easily  discouraged  and  crying ;  in  graver  defect  the  patient  becomes  con- 
fused, forgetful,  devoid  of  emotions';  they  stand  around  dull  and  lamenting  monot- 
onously. Others  become  inaccessible,  childish,  are  in  an  attitude  of  self-defense, 
gesticulate  and  mumble  to  themselves.  The  loss  of  weight  usually  continues. 
Autopsies  merely  showed  extensive  arteriosclerosis,  and  in  two  older  cases  signs  of 
beginning  cerebral  atrophy. 

"Sixty'per  cent,  of  the  cases  are  women  ;  most  of  the  attacks  occur  between  fifty 
and  sixty.     Etiologieally,  heredity  is  moderately  prominent  (frequently  arteriosclero- 
43 


674  MENTAL  DISEASES. 

tic  disorders);  constitutional  oddness  and  external  condition  seem  to  play  a  great 
part. 

Kraepelin's  description  includes  most  cases  of  anxious  malancholias,  depressive 
"  Wahnsinn,''  and  the  senile  depressions.  It  ascribes  all  the  depressions  of  younger 
j'ears  to  manic-depressive  insanity  or  dementia  praecox,  a  few  to  degenerative  insanity 
and  perhaps  also  to  hysteria.  Manic-depressive  insanity  which  may  begin  in  the 
period  of  involution  shows  a  more  rapid  and  favorable  course,  signs  of  manic  traits, 
such  as  considerable  impulse  to  activity,  flight  of  ideas,  exalted  ideas,  cheerfulness, 
without  any  signs  of  dementia  ;  in  the  actual  depression,  the  behavior  of  a  case  of 
melancholia  forms  throughout  the  natural  expression  of  their  anxious  or  irritable 
mood ;  whereas  in  manic-depressive  cases,  indecision,  retardation,  and  inhibition 
of  all  voluntary  actions  stands  in  the  foreground.  On  the  other  hand,  whenever 
they  do  show  irritability,  it  is  always  accompanied  by  vivid  response  in  conduct  and 
utterances,  whereas  the  irritability  of  the  melancholic  bears  the  stamp  of  inward 
anxiety.  Recurrences  are  observed  in  15  per  cent.  In  some  of  the  cases  it  seems 
that  a  previous  attack  occurred  in  the  fourth  decade. 

Transitions  to  senile  confusion  are  quite  gradual.  A  differential  diagnosis  from 
dementia  prsecox  will  come  into  question,  especially  where  catatonic  signs  of  rigid 
negativism,  peculiar  siUy  excitements,  and  mannerisms  develop,  especially  where  the 
patient  is  otherwise  composed  and  oriented.  The  differential  diagnosis  from  general 
jDaralysis  is  said  to  be  most  difficult. 

About  a  dozen  cases  that  Kraepelin  has  seen  within  ten  years,  induce  him  to 
describe  separately  a  presenile  state  of  gradual  development  of  great  weakness  of 
judgment  with  delusion  formation  and  increased  emotional  irritability.  Many 
hypochondriacal  traits  remind  one  of  hysteria  ;  the  delusions  are  fleeting  ;  they  lack 
the  connection  and  elaboration  of  paranoia,  and  the  patient  is  quite  inconsistent. 
Women  are  attacked  in  the  forties  or  fifties,  men  a  little  later.  Heredity  is  almost 
constant.  The  exclusion  of  dementia  praecox  is  made  probable  by  the  absence  of 
catatonic  signs ;  what  may  resemble  them  is  not  simjily  impulsive,  but  always 
founded  on  delusions.  The  termination  is  never  profound  dementia,  but  a  moderate 
weakness  with  a  few  changeable  and  disconnected  delusions. 

We  now  turn  to  the  works  which  take  a  different  standpoint. 

The  older  writers  on  mania  and  on  melanclioUa  were  obviously  in  as  decided  a 
position  as  the  one  taken  by  Kraepelin,  when  they  grouped  together  the  recoverable 
and  the  deteriorating  first  or  second  attacks  as  manias  and  melancholias.  They 
considered  it  impossible  to  make  a  distinction  according  to  the  outcome  clearly  from 
the  start.  On  the  other  hand,  they  i^retend  that  the  attacks  of  periodic  mania  are 
distinguishable  from  the  simple  non-recurrent  attacks  ;  at  least  they  give  rules  of 
distinction  and  they  make  a  great  case  of  the  distinction  of  excitement  and  depres- 
sion. 

On  the  Euroi^ean  continent  the  acute  psychoses  have  long  been  divided  into  more 
specific  groups.  Meynert's  amentia  and  the  types  of  Wahnsinn  withdraw  a  large 
number  of  those  cases  in  which  a  true  depression  or  a  true  exaltation  could  not  be 
called  the  chief  and  leading  feature.  This  purified  the  groups  of  mania  and 
of  melancholia.  Mania  as  described  by  Mendel  (1881)  is  not  essentially  different 
from  what  Ziehen  and  the  earlier  editions  of  Kraepelin  implied  by  it.  Since  our 
whole  discussion  would  lack  a  safe  foundation  if  I  should  take  for  granted  the 
reader's  knowledge  of  the  subdivisions,  I  give  a  summary  of  Ziehen's  groupings, 
referring,  however,  to  Schtile's  "  Psychiatrie"  as  the  best  exponent  of  the  older 
standpoint  which  governed  the  dissolution  of  the  huge  groups  of  what  is  called 
mania  and  melancholia  in  Anglo-American  psychiatric  literature. 

Ziehen  also  adheres  to  the  restricted  types.  From  his  first  edition  he  requires 
for  the  diagnosis  of  mania — (1)  exhilaration  ;  and  (2)  acceleration  of  the  association 
of  ideas,  and  as  part  of  the  latter,  motor  agitation.  All  the  symptoms  must  be 
derived  from  this  formula.  This  leads,  indeed,  to  a  picture  identical  with  Kraepe- 
lin's pure  manic  phase.  Ninety  per  cent,  are  said  to  recover,  5  per  cent,  die  of  in- 
tercurrent diseases ;  according  to  the  first  edition,  in  10  per  cent,  (probably 
misprint?),  according  to  the  second  edition,  in  6  per  cent.,  there  is  merely  a 
"recoveiy  with  defect  "  or  a  real  secondary  dementia.  This  termination  seems  to 
occur  usually  in  "patients  who  have  had  several  previous  attacks  and  finally 
succumb  to  a  severe  one."  (A  publication  of  these  cases  would  be  very  valuable.) 
Very  rarely  a  case  passes  into  secondary  paranoia,  or  into  chronic  mania  with 
persistent  hilarity,  flight  of  ideas,  and  motor  restlessness  without  any  intellectual 
defect.     Even  including  the  periodic  forms,  mania  is  a  rare  disease — only  three  or 


A  REVIEW  OF  RECENT  FBOBLEMS  OF  FSYCHIATBY.  675 

four  per  cent,  of"  tlie  admissions.     A  safe  distinction  from  ])criodic  mania  and  cir- 
cular insanity  does  not  exist.     Periodic  mania  is  probable  where  we  see  : 

1.  The  depressive  initial  stage  very  little  developed. 

2.  The  rise  and  the  decrease  of  exaltation  very  sudden. 

3.  Relation  to  menstruation. 

4.  Very  marked  heredity. 

5.  Hypomania  with  reasoning  traits. 

Circular  insanity  is  probable  where  the  initial  depression  is  long  and  where  de- 
pressions lasting  hours  or  days  interrupt  the  manic  picture.  A  diagnosis  is  only 
possible  after  more  than  one  double  attack. 

Ziehen  distinguishes  irregular  recurrences  from  the  periodic  form  (especially 
frequent  with  hypomania). 

Melancholia,  according  to  Ziehen,  is  similarly  limited  to  those  cases  which 
develop  and  run  their  course  with  a  morbid  primary  depression  (with  a  decided  true 
affect  of  sadness),  and  a  primary  inhibition  of  thought.  The  effect  on  the  motor 
sphere  is  also  that  of  inhibition  ;  but  this  effect,  as  that  of  unrest  in  mania,  is  a 
consequence  of  the  general  disorder  of  cortical  associations.  He  describes  the 
simple  melancholic  depression,  and  the  graver  forms,  and  includes,  further,  the  cases 
with  anxiety,  even  if  anxiety  is  the  most  prominent  and  even  initial  symi)tom. 
Recovery  is  complete  in  90  per  cent,  of  the  cases.  After  long  duration  there  may 
remain  a  certain  difficulty  for  complicated  topics.  In  but  few  cases  silly  laughter 
ushers  in  a  secondary  dementia,  with  increasing  number  of  hallucinations  and  defects 
of  memory  and  judgment.  Or  the  melancholia  lasts  and  becomes  chronic. 
Secondary  paranoia  is  rare.  There  is,  however,  a  great  tendency  to  recurrences, 
sometimes  after  a  score  of  yeai's  or  more  (such  as  one  attack  at  puberty,  and  one  in 
the  climacteric  period) ;  or  to  real  periodicity.  Hallucinatory  melancholia  is  not  as 
favorable  and  there  are  all  grades  of  transition  to  hallucinatory  paranoia.  Or 
melancholia  may  be  part  of  circular  insanity.  In  the  latter,  Ziehen  claims  the  oc- 
currence of  secondary  dementia  in  10  per  cent.  As  to  frequency,  circular  insanity 
precedes  all  other  psychoses  (?). 

Stupidity,  a  disorder  characterized  almost  altogether  by  inhibition  of  all  asso- 
ciation of  ideas  with  practically  no  affect,  is  credited  with  60  per  cent,  of  recoveries. 
Recovery  with  defect,  rather  more  rarely  pronounced  secondary  dementia,  or  occa- 
sionally secondary  paranoia,  or  death  by  intercurrent  disease,  or  permanent  apathy, 
make  up  the  other  40  per  cent.  It  is  said  to  be  an  exhaustion  disease  of  early 
years  and  rare  after  the  thirty-fifth  year.  How  often  recurrences  are  seen  is 
not  said. 

A  large  group  of  what  in  Anglo-Saxon  statistics  is  customarily  classed  as  mania 
and  melancholia,  is  put  under  the  heading  of  paranoia,  i.  e. ,  disorders  on  delusional 
or  hallucinatory  basis.  Here  only  the  acute  forms  interest  us.  The  acute  simple 
paranoia  without  hallucinations  is  always  recovered  from,  but  has  a  great  ten- 
dency to  recurrence.  Numerous  and  changeable  delusions  come  up,  with  variable 
affect ;  there  is  a  secondary  acceleration  of  ideation  and  agitation  ;  orientation  may 
suffer.  The  duration  is  rarely  more  than  three  weeks.  The  frequency  is  not  men- 
tioned. Far  more  frequent  is  the  aaite  hallucinatory  paranoia  which  Ziehen 
identifies  with  Meynert's  amentia,  or  Ftirstner's  confusional  insanity,  which  shows 
all  stages  between  pseudo-stupor  and  great  agitation.  Nearly  70  per  cent,  recover 
(usually  within  less  than  one  year),  but  many  of  these  show  recurrences  in  one,  two, 
or  three  years,  and  very  often  the  second,  third,  or  fourth  recurrence  leads  to  secon- 
dary dementia  or  chronic  hallucinatory  paranoia.  Scarcely  30  per  cent,  remain 
permanently  well.  Secondary  dementia  follows  the  first  attack  in  at  least  15  per 
cent,  of  all  the  cases,  especially  in  young  persons  ;  usually  the  patients  begin  to  give 
silly  replies  also  outside  of  their  hallucinatory  agitation.  The  parallelism  between 
affect  and  delusions  is  gradually  lost,  etc.  Chronic  hallucinatory  paranoia  may  come 
about  through  cuiiiulation  of  many  recurrences,  or  following  a  single  attack ; 
delusions  preponderate  over  hallucinations,  and  the  auditory  hallucinations  over  the 
visual  ones.  Death  is  very  frequent  in  those  forms  which  are  known  as  delirium 
acutum.  (Ziehen  also  classifies  delirium  tremens  as  a  peracute  hallucinatorj^  para- 
noia, "which  occurs  exclusively  in  chronic  alcoholism.")  Ziehen  also  speaks  pf 
periodic  acute  hallucinatory  paranoia  (periodic  amentia),  with  unfavorable  prognosis ; 
and  of  the  much  rarer  periodic  acute  simple  non-hallucinatory  paranoia  ;  and  finally 
of  circulai'  paranoia,  (the  type  of  acute  hallucinatory  paranoia  with  flight  of  ideas 
frequently  passes  into  a  stuporous  phase  and  the  cycle  may  recur).  Recoveries  are 
rare  ;  but  the  intervals  may  grow  longer.     Finally  he  classes  those  forms  of  periodic 


676  MENTAL  DISEASES. 

insanity  in  which  the  types  vary  irregularly  (mania,  rnelancholia,  and  various  forms 
of  acute  hallucinatory  paranoia),  as  polymorphous  periodic  insanity.  In  a  foot-note 
he  adds  :  ''  The  attempt  of  Kraepelin  to  combine  all  the  periodic  and  circular  psy- 
choses and  simple  mania  (and  in  part  also  melancholia)  into  one  disease  group,_as 
'manic-depressive  insanity,'  comes  from  a  confusion  of  tendency  to  recurrence  with 
periodicity." 

On  reviewing  this  brief  summary  (to  do  Ziehen  justice  one  ought  to  read  his 
descriptions,  of  which  only  a  bare  skeleton  is  given  here,  sufficient  to  hold  forth  the 
important  issues  of  discussion),  one  sees  in  most  forms  the  admission  of  "  innumer- 
able types  of  transition,"  and  the  division  is  recommended  on  account  of  psj'cho- 
logical  clearness.  Ziehen  does  not  state  how  many  cases  are  of  doubtful  classifica- 
tion ;  nor  does  he  attempt  especially  to  single  out  the  types  of  poor  prognosis  as  far 
as  lasting  defects  go.  Acute  simple  paranoia  has  an  absolutely  good  prognosis,  next 
comes  mania  and  melancholia  with  90  per  cent.,  and  finally  acute  hallucinatory 
paranoia  (which  includes  forms  with  or  without  disorientation,  and  only  excludes  the 
symptomatic  deliria,  and  the  psychoses  of  epilepsy,  hysteria,  etc.,  from  what  is 
often  called  "delirious  mania"  in  America),  with  70  per  cent,  and  only  40  per 
cent,  without  recurrence  in  ten  years,  or  30  per  cent,  without  any  recurrence.  Just 
this  last  statement  might  well  be  taken  cum  grano  sails.  We  shall  also  see  the 
great  importance  of  investigating  and  grouping  the  cases  as  to  whether  the  attack 
shows  a  sufficient  or  a  trivial  constellation  of  etiological  factors,  a  point  not  sufficiently 
used  by  Ziehen.  Stupidity  stands  last  among  the  acute  psychoses,  as  recoverable 
only  in  60  per  cent.  To  complete  the  list  of  what  is  commonly  classed  as  acute 
insanity  in  this  country,  we  must  include  7Ae\i&n  a  states  of  clouded  consciousness. 
He  separates  them  from  acute  and  peracute  hallucinatory  paranoia,  because  of  their 
sudden  onset  and  termination,  their  short  duration  (minutes,  hours,  or  days),  the 
almost  constant  defects  of  memory  (amnesia)  for  the  condition,  ' '  such  as  hardly  ever 
occurs  in  acute  hallucinatory  paranoia,  including  delirium  tremens,"  and  finally  because 
orientation  and  coherence  of  the  association  of  ideas  are  always  interfered  with, 
while  hallucinations  and  delusions.may  be  absent  in  exceptional  cases.  He  admits 
that  there  is  no  sharp  limit.  He  finds  these  states  related  to  sleep  and  som- 
nambulism, to  hypnotism,  to  epilepsy  (with  numerous  types),  to  hysteria,  and  finally 
on  toxic,  congestive,  and  angiospastic  ground,  or  connected  with  migraine,  neural- 
gias, affects,  and  traumatisms.  Finally,  he  treats  the  symptomatic  deliria  (I,  in- 
fective or  febrile  ;  2,  toxic  ;  3,  on  ground  of  defei-vescence  or  collapse ;  4,  on 
ground  of  inanition),  the  deliria  of  seclusion  in  the  dark  and  the  disorders  on  com- 
pulsive ideas. 

Passing  to  Wernicke,  we  are  put  on  totally  difierent  ground.  No  longer  the 
skeleton  of  a  psychology  which  could  as  well  be  derived  from  permutations  of 
concepts  of  traditional  psychology  (affect,  ideas,  hallucinations  and  delusions,  and 
trend  of  association,  and  memory),  but — -simple  psychiatric  observation?  Yes,  to  a 
large  extent,  though  characteristically  stamped  by  a  special  terminology,  only  in  part 
derived  from  the  very  excellent  and  faithftil  method  of  observation  and  description 
which  we  have  praised  in  Wernicke.  We  continue  our  analysis  interrupted  in  the 
earlier  part  of  this  chapter. 

To  start  with,  we  find  Wernicke's  anxiety  psi/cliosis  separated  from  melancholia, 
as  with  Kraepelin,  who,  however,  preserves  the  name  melancholia  for  just  these 
forms  and  classes  them  as  disorders  of  involution,  as  largely  occurring  in  the  climac- 
teric or  post-climacteric  period.  We,  therefore,  need  not  consider  it  in  our  corre- 
lation with  manic-depressive  insanity.  It  is  sufficient  to  say  that  Wernicke  sees  in 
his  anxiety  ps3'chosis  anxiety  as  the  fundamental  trait,  the  source  of  moi'bid  concepts, 
which  are  autopsychic  in  slight  anxiety,  allopsychic  and  somatopsychic  in  deeper 
forms.  The  ideas  will  often  appear  as  phonemata  (voices),  and  the  other  senses  may 
hallucinate  during  the  height  of  the  affect,  in  epileptics  even  in  the  form  of  com- 
bined hallucination.  The  self-appreciation  of  the  patient  shows  always  depressive 
traits,  while  allopsychic  orientation  remains  intact,  or  is  only  disturbed  by  irradiation 
of  the  perplexity  and  ideas  of  reference.  The  deductions  from  self-accusations  lead 
to  fear  of  ruin  even  of  the  family,  and  to  fear  of  danger  through  others.  Alcohol- 
ism, epilepsy,  the  climacteric  period,  and  senescence  furnish  the  ground  for  this 
form.  The  allied  somatopsychoses  are  probably  to  be  grouped  with  the  para- 
noic psychoses.  Wernicke  admits,  however,  a  certain  group  of  transition  cases 
between  anxiety  psychosis  and  affective  melancholia  (see  later),  especially  in  young 
people  and  in  senility,  and  always  with  a  good  prognosis.  The  depression  is  more 
even,  anxiety  is  subordinate  ;  allop.sj'chic  ideas  are  subordinate.     Further,  certain 


A  REVIEW  OF  RECENT  PROBLEMS  OF  PSYCHIATRY.  67  / 

t'oi'iiis  uf  ruelaiiL-hulia  agitata  may  n>usist  at  times  uf  a  mixture  of  anxiety  psy- 
chosis and  the  manic  symptoms  of  fliglit  of  ideas  and  flow  of  woi'ds.  The  acute 
hallucinosis  (simply  hallucinatory  insanity  without  disorientation)  comes  under  con- 
sideration, inasmuch  as  not  all,  thousih  most,  of  the  cases  are  of  alcoholic  origin,  and 
because  it  might  be  mixed  up  with  anxiety  psychosis.  It  is,  however,  more  essen- 
tially hallucinatory,  more  continuous  (much  more  independent  in  its  course  from 
the  degree  of  anxiety  as  such).  As  acute  expansive  autojjsychosis  Wernicke  presents 
(ji.  oli-i)  a  case  of  acute  delusional  insanity,  n(jt  uidike  a  beginning  of  general  paralysis 
— a  man  of  thirty-eight,  who  had  an  attack  of  nervous  excitement  at  seventeen,  and  a 
young  man  of  twenty-two  with  a  ])eculiar  attack  on  a  basis  of  autochthonous  ideas 
with  one  short  intermission,  not  purely  "delusional,"  but  apparently  with  a  rush 
of  ideas. 

The  range  of  the  disease-groups  which  is  quite  certainly  covered  with  Kraepelin's 
manic-depressive  insanity  is  taken  up  on  page  337.  Wernicke  i)resents  two  cases 
showing  a  diametrically  different  picture,  one  of  affective  melancholia,  and  one  of 
mania,  instances  of  pure  depression  and  pure  exaltation,  and  associated  with  them 
intrapsychic  afunction  or  hypofunction,  and  intrapsychic  hy]XMfunction.  From  the 
point  of  view  of  contents  of  consciousness,  "autopsychic  orientation  "  suffers  first 
in  the  form  of  self-depreciation  or  exaltation  (megalomania). 

First  comes  melancholia  with  its  intrapsychic  afunction,  which  shows  at  once  in 
the  difficulty  of  decision,  and  the  dread  of  the  future  and  the  i'eeling  of  subjective 
insuflicieucy.  There  is  a  dulling  of  interest  and  psychic  feeling,  a  feeling  of  empti- 
ness of  life,  self-accusation  over  the  "neglect,"  a  feehng  of  unhajjpiness  (a  special 
form  of  autopsychic  perplexity,  whereas  hypochondriacal  depression  is  a  somato- 
psychic perplexity).  Then  objective  symptoms  develoj)  :  an  inactivity  (intrapsychic 
akinesis)  in  speech  and  action.  An  actual  retardation  due  to  great  difficulty  of 
reaction  goes  beyond  the  simple  picture  called  affectii-e  melancholia  by  Wernicke.  He 
ascribes  to  '^  chpressive  melancholia''''  (which  had  better  be  called  hy|)okh)etic  mel- 
ancholia or,  even  better,  hypokinesis  ;  and  which  is  probably^  [see  p.  443]  a  jiroduct 
of  deduction  from  the  general  schema)  initiative  mutism  and  initiative  akinesis  ;  also 
diminution  of  expressive  motions,  hut  less  of  simple  reactive  motions  ;  the  affect  of 
subjective  insufficiency  also  vanishes ;  instead  of  dominant  thoughts,  there  is  a 
dearth  of  thoughts ;  the  fear  of  bodily  danger  might  still  allow  of  anxiety  ;  but 
there  is  no  flexibilitas,  pseudo-flexibilitas,  rigidity,  or  negativism._  Affective 
melancholia  also  may  show  anxiety  as  an  immediate  consequence  of  theintrapsychic 
inhibition,  and  on  the  same  grounds,  dominant  ideas  of  a  hypochondriacal  nature. 
Moreover,  there  are  disorders  of  appetite,  cool  extremities,  etc.  In  severer  types  o^ 
affective  melancholia,  an  irradiation  may  lead  to  fantastic  depressive  delusions — so 
many  people  are  sick,  the  world  will  come  to  an  end  ;  the  patient  is  not  human,  can 
never  die.  It  may  also  lead  to  refusal  of  food,  to  isolated  visions,  or  to  phonemata. 
The  course  is,  as  a  rule,  continuous  ;  the  attack  is  often  followed  by  a  short  manic 
condition.  Very  few  cases  become  chronic.  Even  in  this  very  narrow  limitation 
affective  melancholia  is  a  very  frequent  psj^chosis.  It  is  easily  distinguished  from 
the  anxious  psychosis  (which  has  more  fluctuations,  little  feeling  of  subjective  insuf- 
ficiency, and  more  allopsychical  elements,  and  not  even  an  indication  of  retardation). 
The  distinction  from  hysterical  and  neurasthenic  states  of  anxiety  is  somewhat  jess 
easy,  especially  where  "the  latter  have  a  very  pronounced  impulsive  desire  for  suicide. 
Depressive  autopsychoses  show  circumscribed  autopsychic  delusions  of  reference  of 
the  nature  of  dominant  ideas  (self-reproach  over  the  death  of  a  relative),  or  of 
compulsive  ideas,  and  are  a  picture  distinct  from  affective  melancholia. 

This  brief  sketch  will  show,  I  think,  how  painstaking  and  true  to  facts 
Wernicke  is  in  his  discriminations  in  this  one  lai'ge  complex  of  cases  which  are  all 
juggled  together  as  melancholia  in  our  statistics.  Wernicke  claims  for  the  small 
well-outlined  group-  of  affective  melancholia  a  perfectly  good  prognosis,  even  in 
advanced  age,  although  there  the  chances  of  recurrence  become  greater.  He 
recognizes  the  relationship  with  those  depressions  which  Kraepelin  describes  in 
manic-depressive  insanity,  but  denies  that  recurrence  is  the  rule,  except  where  the 
attacks  set  in  and  end  abruptly.  He  fiiils,  however,  to  give  an  exact  statement  of 
his  actual  experience.  Other  depressions,  not  in  the  frame  given_  here,  luust  be 
analyzed  and  classed  as  different.  It  would  seem,  though,  that  the  limit  of  affective 
melancholia  and  depressive  melancholia  is  not  as  pronounced  and  not  as  essential  as 
Wernicke  makes  out.  As  especially  pleasing  to  me,  I  refer  once  more  to  the  simple 
statement  that  affective  melancholia  consists  in  depression  plus  intraps.vchic  akinesis, 
instead  of  what  Ziehen  and  Kraepelin  speak  of  as  '"'Hemmung,'"  or  inhibition,  a 


678  MENTAL  DISEASES. 

term  too  easily  used  and  apt  to  suggest  a  deus  ex  machina.     The  simple  description — 
akinesis,  or  retardation — is  decidedly  more  objective. 

On  his  instance  of  simple  mania,  Wernicke  describes  first  the  flight  of  ideas,  in 
which  the  accidental  fails  to  be  suppressed  (attention  is  not  normally  held  to  a  topic 
except  with  an  efi"ort,  or  not  even  then).  The  purely  affective  simple  mania.,  how- 
ever, does  not  reach  a  degree  of  decided  incoherence.  The  morbid  euphoria  leads 
to  autopsychic  disorientation  in  the  form  of  exalted  ideas  and  delusions,  which  may 
even  become  fantastic,  but  change  easily  and  are  more  whims  than  convictions.  The 
increased  activity  of  association  leads,  further,  to  a  certain  degree  of  distractibility 
(totally  different,  however,  from  true  hypermetamorphosis),  and  to  inconsiderate  and 
hasty  action  and  even  irascibility.  In  addition  to  this,  a  veritable  unrest  leads  to 
almost  compulsive  overactivity  and  tendency  to  useless  pranks,  and  a  great  produc- 
tivity in  talk  with  puns  and  alliterations.  Only  when  irascibility  is  prominent  do  we 
find  temporary  intermissions  from  talking.  In  it  all  there  is  a  distinct  leveling  down 
of  the  normally  dominant  trend  of  thought,  the  very  reverse  of  what  happens  in 
affective  melancholia  ;  egoism,  lying,  lack  of  modesty,  and  a  total  change  of  "  char- 
acter ' '  develop.  The  rare  and  merely  occasional  phonemata  seem  to  be_  largely 
expressions  of  ideas  of  exaltation.  The  general  condition  of  the  patient  is  good. 
The  onset  is  usually  rapid,  the  recovery  a  little  slower.  Apart  from  intercurrent 
risks,  mania  in  this  sense  is  the  most  recoverable  mental  disorder.  It  occurs  like 
affective  melancholia,  chiefly  on  a  basis  of  heredity  and  neurotic  degeneracy. 

Wherever  additional  symptoms  occur  they  determine  a  different  diagnosis. 
Wernicke  mentions  paralytic  mania  (the  exaltation  is  one  of  conviction),  the  hyper- 
kinetic traits,  and,  especially  in  the  recurrent  forms  of  mania,  phases  of  confusion 
(depending  on  flight  of  ideas,  and  only  in  severer  cases  complicated  by  additional 
elements).  Wernicke  speaks  of  the  great  tendency  to  recurrence,  of  the  peculiar 
relation  to  affective  melancholia,  of  the  spurious  and  veritable  circular  forms.  The 
fact  that  he  excludes  from  his  picture  what  appears  at  the  height  of  most  attacks  of 
mania,  and  what  is  bound  to  occur  in  the  course  of  recurrences,  shows  how  firmly 
Wernicke  adheres  to  the  symptom-complexes  and  how,  in  contrast  to  the  broader 
clinical  attitude  of  Kraepelin,  he  is  not  in  the  least  concerned  about  the  cases  which 
do  not  fit  his  definitions.  That  he  also  admits  a  chronic  mania,  i.  e. ,  a  chronic  per- 
sistent picture  like  the  one  described,  although  he  is  sure  that  it  never  develops 
from  acute  simple  mania,  would  be  another  deviation  from  Kraepelin' s  standpoint, 
to  whom  general  course  and  bearing  mean  more  than  symptomatic  make-up  of  the 
disorder  as  such. 

That  which  constitutes  the  majority  of  the  ordinary  manias  in  the  international 
traditional  meaning  of  the  word  is  treated  by  Wernicke  under  hyperkinetic  motility 
psychosis  and  confused  mania.  The  term  delirium  does  not  appear,  and  Meynert's 
amentia  is  dealt  with  under  "  confused  mania."  This  general  group  obviously  con- 
tains, therefore,  many  cases  which  Ziehen  classes  as  acute  hallucinatory  paranoia, 
since  Wernicke's  acute  hallucinosis  excludes  those  with  disorientation  as  to  time, 
place,  and  person. 

For  the  sake  of  closer  connection  we  shall  first  review  Wernicke's  lecture  on  con- 
fused mania  or  agitated  confusion.  Clinically  (Wernicke  himself  uses  this  word 
here),  it  is  an  acute  psychosis  which  may  begin  and  end  as  a  mania,  but  in  its  course 
presents,  in  addition  to  the  symptoms  of  pure  mania,  psycho-sensory  and  psycho- 
motor "  disorders  of  identification."  When  the  purely  manic  phases  are  very  in- 
significant, we  do  well  to  speak  of  agitated  confusion,  in  which  the  sensory  or  the 
motor  agitation  may  be  more  prominent.  Usually  the  sensory  and  the  motor  agita- 
tion are  combined.  When  the  motor  agitation  prevails,  we  find  transitions  to  the 
hyperkinetic  motility-psychoses.  The  confusion,  as  such,  is  not  the  decisive  feature. 
We  must  distinguish  whether  the  confusion  is  a  symptom  of  irritation  and  allied  to 
the  productivity  of  speech,  of  flight  of  ideas,  or  whether  it  is  a  condition  of  defect, 
a  simple  incoherence  from  dissociation  or  sejunction.  Only  the  former  is  to  be  con- 
sidered here.  Confused  mania  is  limited  to  associative  excitability,  in  which  the 
attention  of  the  patient  is  fleeting,  but  not  so  that  it  could  not  be  flxed  for  moments ; 
in  which  the  incoherence  is  a  formal  disorder,  a  simple  exaggeration  of  intrapsychic 
hyperfunction,  a  flight  of  ideas,  in  which  similarities  of  words  play  a  great  role,  and 
in  which  we  may  lose  the  appreciation  of  connection  between  the  words  and  frag- 
ments of  words  produced.  In  this  sense  confused  mania  occurs  as  the  acme  of  rare 
cases  of  simple  mania  ;  it  is  much  more  frequent  in  recurrent  mania  and  especially 
in  periodic  mania,  and  most  frequent  in  that  of  menstrual  origin.  The  cases  he 
mentions  are  splendid  pictures  of  what  is  called  mania  by  KraepeUn  and  by  all  others 


A  REVIEW  OF  RECENT  PROBLEMS  OF  PSYCHIATRY.  679 

who  limit  the  use  of  the  term  to  the  simple  exaggeration  of  hypomania.  Thus,  he 
sums  up  a  fifth  attack  of  periodic  puerperal  mania  in  a  patient  (whose  first  attacks 
had  liad  more  the  features  of  a  hyperkinetic  motility-jisychosis) ;  incoherent  flight 
of  ideas  with  occasional  quick  appropriate  replies,  an  exuberant  exalted  attitude  and 
correspondingly  exaggerated  expressive  motions,  impulsive  motor  activity  expressed 
by  tearing  and  swearing  ;  immodest  manners  ;  in  addition  to  this,  an  admixture  of 
motor  hyperkinesis,  acting  as  a  chansonette  singer,  and  hypermetamorphosis.  With 
this  form,  periodic  mania  is  not  exhausted.  Wernicke  singles  out  all  cases  with 
even  temporary  allopsychic  disorientation  (non-recognition  of  place,  situation,  and 
persons  and  objects),  and  deeper  disorders,  and  calls  them  phases  or  attacks  of 
periodic  maniacal  allopsychosis.  Even  very  prominent  flight  of  ideas  need  not 
produce  disorientation  ;  on  the  other  hand,  the  periodic  maniacal  allopsychosis  may 
become  a  "total  sensory  psychosis."  The  incoherence  always  affects  first  the  auto- 
psychic  field,  and  only  in  the  second  and  third  place  the  allopsychic  (appreciation  of 
the  outside  world)  and  the  somatopsychic  field  (the  most  fundamental  consciousness 
of  the  somatic  feelings).  Besides  the  confusion  through  precipitation  of  activity, 
Wernicke  describes,  further,  the  asthenic  confusion,  either  following  very  severe 
excitements  of  confused  mania  (a  good  description,  by  Wernicke,  p.  405),  or  primary, 
perhaps  totally  independent  of  mania — a  picture  resembling  much  more  closely 
Kraepelin's  very  narrow  conception  of  amentia  (a  characteristic  case  is  reported  on 
p.  406).  Meynert's  amentia,  according  to  Wernicke,  would  include  chiefly  his  acute 
autopsychoses,  allopsychoses,  somatopsychoses,  motility-psychoses,  and  their  com- 
binations, implying  various  degrees  oi' weakness  of  association. 

We  now  turn  to  the  motility-psychoses.  We  have  seen  in  a  previous  part  of  this 
chapter  how  Wernicke  comes  to  this  term.  On  reading  his  lectures,  we  find  our- 
selves confronted  with  a  vast  material,  exceedingly  difficult  to  abstract,  and  ob- 
viously covering  forms  of  very  heterogeneous  bearing  for  a  comparison  with  Kraepe- 
hn's  groupings. 

Wernicke  presents  a  patient  of  twenty- seven,  who  passed  through  a  normal  con- 
finement ;  on  her  return  from  the  lying-in  hospital  she  showed  abnormal  anxiety 
about  the  child,  and  the  second  night  began  to  sing  and  dance  and  talk  of  hearing 
angels  sing.  The  next  day  she  mistook  her  husband  for  the  physician.  For  four 
weeks  she  had  been  in  continuous  motion,  with  mostly  theatrical-pathetic  expressive 
movements  and  a  peculiar  chanting  accompanied  by  an  odd  rapid  tremor  of  the  lower 
jaw,  unhappy  facial  expression,  and  refusal  of  food.  This  condition  had  passed  into 
one  of  exhaustion,  vacant  staring,  still  exaggerated  but  greatly  variable  mimic  play 
(she  shows  the  white  of  her  eyes,  then  frowns,  or  pouts  or  pushes  forward  her  jaw), 
and  occasionally  oddity  in  pronunciation  ;  whereas  at  other  timesshe  talks  plainly, 
gives  her  name,  the  date  of  her  confinement,  complains  of  dizziness  and  fatigue, 
recites  the  Lord's  prayer  correctly,  but  adds  an  explanation  to  one  of  the  ten  com- 
mandments and  begins  a  choral,  quite  con-ectly,  but  without  being  asked  ;  at  times 
she  looks  aside  as  if  listening,  or  at  the  nurse  as  if  for  help  ;  she  has  difficuhy  in 
directing  her  attention.  She  allows  the  arm  to  be  elevated  and  holds  it  there 
a  while  ^  bending  of  the  head  is  slightly  painful.  The  mood  varies  between  apathy, 
euphoria,  irritation,  and  perplexity,  and  orientation  is  imperfect ;  there  are  even 
some  somatic  complaints  (that  she  had  been  hunchbacked  last  night).  Dancing  and 
singing  seemed  to  her  as  if  forced  on  her.  The  patient  is  later  demonstrated  again 
in  a  state  of  catatonic  stupor.  From  this  picture  Wernicke  analyzes  especially  the 
hyperkinetic,  parakinetic,  and  occasional  akinetic  traits. 

On  page  374  he  gives  another  splendidly  characteristic  picture  of  an  unmarried 
woman  of  thirty-six,  who  had  a  depression  of  three  months  at  twenty-eight,  and 
lately  a  brief  premenstrual  excitement,  and  two  months  later  this  typically  hyper- 
kinetic attack:  The  patient  comes  in  dancing,  singing  a  waltz-tune  ;  five  times  she 
puts  the  flat  hand  on  the  head,  says  "holy  water"  and  bows;  she  sits  down  on 
request,  but  gets  up"  again,  bends  forward  so  as  to  throw  her  hair  over  her  face,  and 
repeats  this  twenty  times ;  then  she  goes  about,  gesticulating  and  talking  discon- 
nectedly, with  emphasis  where  her  movements  are  emphatic.  Her  mood  as  well  as 
the  motions  vary  continually ;  at  times  they  are  overcheerful,  at  times  exalted  or 
irritable  ;  only  rarely  does  she  give  a  correct  reply ;  usually  she  ignores  questions, 
while  she  is  obviously  easily  guided  in  her  motions  by  casual  impressions.  Her 
fragmentary  talk  is  remarkably  adapted  to  the  temporary  activities — there  is,  as  it 
were,  a  flight  of  activity  with  associated  flight  of  words.  _  The  whole  performance 
might  he  called  hysterical,  but  it  continues  when  nobody  is  present,  and  after  the 
attack  the  patient  gives  a  clear  description  of  the  pseudo-spontaneous  and  inexpli- 


680  MENTAL  DISEASES. 

cably-forced  nature  of  the  inovemeDts.  They  have  a  certain  monotony  and  even 
rhythm  which  may  be  accompanied  by  verbigeration  ;  the  motions  are  exaggerated, 
obviously  unpremeditated,  more  adaptive,  or  directly  forced.  The  patient  sings,  or 
goes  through  gymnastics,  although  she  does  not  feel  like  it.  Not  infrequently  there 
are  phases  of  mutism.  Almost  always  we  observe  hypermetamorphosis.  i.  e. ,  a  com- 
pulsive distractibility  of  the  trend  of  thought.  When  the  latter  is  not  much  discon- 
nected, there  is  nevertheless  a  tendency  to  false  pathos,  biblical  oratory  and  an  empty 
form  of  preaching.  In  two  further  cases  Wernicke  describes  a  remarkably  pure 
picture  of  motor  reaction  to  a  peculiar  motor  uneasiness,  "  jactatoid  (or,  we  might 
say,  jactation  like)  motor  unrest. ' '  Wernicke  describes  choreatic  unrest,  also  certain 
types  of  impulsive  actions  (one  case  actually  with  one  week's  exacerbation  of  the 
nature  of  choreatic  motor  unrest),  probably  because  these  show  no  additional  mental 
sj^mptoms  such  as  would  be  incompatible  with  the  motility-psychosis.  He,  however, 
excludes  motor  reactions  on  a  directly  hallucinatory  basis  (p.  389) ;  and  ignores  that 
he  might  well  class  some  of  his  instances  of  forced  motions  as  ' '  autochthonous ' ' 
motor  attitudes  or  reactions  (one  instance  of  actual  dementia  prascox,  another  one 
with  recovery),  as  not  so  essentially  different  from  others  with  actually  hallucinatory 
basis.  Like  the  reactions  on  a  hallucinatory  basis,  those  in  the  motor  unrest  of  per- 
plexity have  distinct  marks  of  psychic  motives ;  also  those  in  delirium  (tremens  or 
paralytic).  The  same  holds  for  the  truly  hypermetamorphic  motor  unrest  (by  irre- 
sistible distractibility,  where  the  sight  of  a  basin  makes  the  patient  wash  himself, 
etc.).  Just  this  form  of  irresistible  distractibility  occurs  often  enough  in  the  hyper- 
kinetic psychoses,  and  might  well  show^  Wernicke  the  danger  of  giving  too  much  im- 
portance to  a  schematic  derivation  and  classification  of  symptoms,  and  of  tearing 
apart  connections  perhaps  more  natural  than  those  of  his  system. 

All  these  types  may  be  covered  by  the  vague  expression  of  maniacal  excitement, 
but  might  well  be  kept  distinct  as  motility-psychosis,  when  no  other  symptoms 
occur.  In  this  way  we  obtain  a  number  of  cases  of  pure  hyperkinetic  psychosis, 
while  in  other  cases  we  merely  find  the  symptom-complex  as  part  of  a  wider  picture. 
The  pure  cases  are  mostly  irregularly  remittent  and  form  a  large  proportion  of  the 
periodic  manias  of  the  statistics,  often  of  menstiTial  or  puerperal  origin,  but  also 
occurring  in  men.  The  attacks  are  usually  short.  The  prognosis  is  generally  good. 
Most  cases  recover  after  a  number  of  periods,  even  when  arising  on  a  hereditaiy  or 
' '  degenerative ' '  basis. 

Wernicke  (page  392)  explicitly  states  that  mania  is  the  only  disease  which  shows 
actual  transitions  to  the  hyperkinetic  motility-psychosis ;  and  for  this  reason  an  inner 
relationship.  On  the  other  hand,  the  hyperkinetic  motilitj^-psychosis  may  be  a 
phase  of  a  cyclic  motility-psychosis  or  an  episode  of  a  ''  total  motility-psychosis.''' 
which  we  must  take  up  here.  It  has  probably  much  bearing  on  catatonia,  which  we 
can  not  treat  fully  here. 

Absence  of  motility,  even  more  than  excess  of  motility,  cuts  us  off  fi-om  con-ect 
information  of  the  mental  life  of  the  patient.  Here  we  need  all  the  more  an  accu- 
rate knowledge  of  what  motor  symptoms  there  are. 

Wernicke  gives  first  a  demonstration  of  the  first  case  of  hyperkinetic  motility- 
psychosis  in  the  akinetic  condition  into  which  she  had  finally  passed  :  a  state  of  ex- 
haustion, motionless  and  without  response  to  calls.  No  fixation  of  the  eyes,  merely 
a  slight  increase  of  the  frequency  of  winking.  The  arms  show  ty]3ical  flexibilitas 
cerea,  the  hip-joints  muscular  rigidity.  The  legs  are  relaxed  ;  the  reflexes  of  the 
legs  are  normal,  those  of  the  arms  increased  ;  the  head  is  freely  movable.  Only 
the  jaws  resist,  and  the  eyelids,  which  had  become  closed  in  spasmodic  weeping 
following  pricks  in  the  face.  Pricks  of  the  arms  had  had  little  effect,  and  the  right 
hand  had  not  been  withdrawn  at  all  ;  the  toes  of  the  foot  went  upward,  and  repeti- 
tion of  pricks  of  the  sole  made  her  bend  the  knee  and  knit  the  eyebrows.  Pain 
evidently  made  her  break  through  the  reactive  akinesis.  Requests  to  move  or  to 
get  up  are  not  responded  to  or  only  veiy  tentativelj' ;  when  started  and  helped,  she 
stood,  followed  like  an  automaton,  but  finally  stood  alone  ;  when  asked  to  walk,  she 
slowly  leaned  over  and,  on  the  point  of  falling,  suddenly  started,  ran  as  in  the  \)vo- 
pulsion  of  paralysis  agitans,  and  happened  to  drop  on  the  couch.  Throughout  this 
test  she_  had  been  sighing  and  weeping.  The  previous  examination  had  shown  dis- 
orientation in  the  three  fields  of  consciousness. 

The  second  case  is  one  resembling  hysteria,  and  is  obviously  lacking  in  detail, 
since  no  examination  for  parasitic  ideas  was  made. 

The  third  case  is  a  delirium  with  episodic  and  later  permanent  akinesis,  with 
temporary  muscular  rigidity  ;  mutism  interrupted  by  inarticulate  outcries  ;  relaxa- 


A  REVIEW  OF  RECENT  PROBLEMS  OF  PSYCHIATRY.  681 

tion  after  the  eleventh  ilay  ;  utterances  over  peculiar  sensations  during  the  third 
week  ;  improvement  during  the  fourth,  and  an  account  of  (teculiar  dream-episodes  ; 
the  patient  felt  that  he  was  a  steamer,  he  had  to  put  togethei'  the  world,  which  had 
gone  to  pieces,  etc.  He  remembers  no  reason  for  the  rigidity.  In  the  seventh 
week  a  slight  relapse  after  an  indiscretion  (feeling  that  the  brain  moved  in  the  skull, 
etc.),  but  complete  and  lasting  recovery. 

The  fourth  case,  a  young  lawyer,  Hebrew,  began  suddenly  with  anxious  per- 
plexity, attempts  at  suicide,  mutism,  negativism,  odd  attitudes.  Death  from 
pneumonia  in  a  few  days.  Then  follow  cases  showing  queer  attitudes,  queer 
rope-dancer's  gait,  etc.;  and  the  record  of  a  young  man  of  thirty-two  who  was  sud- 
denly taken  ill  and  held  his  tongue  squeezed  between  his  jaws  (although  his  eyes 
showed  that  he  was  conscious),  the  same  position  being  held  even  after  the  jaws 
were  separated  in  narcosis.  He  gained  command  over  the  tongue  last  of  all  when 
he  regained  his  movements,  on  recovering  from  the  sleep-like  state  in  a  few  days. 
Comi)lete  i-ecovery. 

Wernicke  gives  an  analysis  of  these  symptoms  of  a  motionless  condition 
(akinesis),  varying  from  apparent  death  to  the  catatonic  stupor  with  mutism,  nega- 
tivism, catalepsy,  rigidity,  lack  of  spontaneity,  parakinesis,  verbigeration,  stereo- 
typies, and  pseudo-flexibility  (on  suggestion) ;  and  he  analyzes  the  depth  of  the 
sensorium  and  defines  in  detail  the  pure  akinetic  motility-psychosis,  which  is  quite 
limited  and  excludes  the  types  of  intrapsychic  origin  of  the  motor  state.  The 
cyclic  and  complete  motility-psychoses  (with  akinetic,  parakinetic,  and  hyperkinetic 
symptoms)  give  an  opportunity  to  discuss  a  few  very  peculiar  pictures.  Among  the 
motility  symptoms  of  psychic  origin  Wernicke  discusses  foremost  his  "  depressive 
melancholia,"  which  I  should  prefer  to  call  hypokinetic  melancholia,  and  he  de- 
fines it  as  a  part  of  a  motility-psychosis,  or  as  a  pseudo-melancholia  showing  dis- 
tinct paranoid  traits,  or  as  parts  of  general  paralysis,  or  as  the  beginning  of  other 
complex  psychoses  (^.  e.,  very  heterogeneous  entities).  In  intrapsychic  akinesis  the 
disorder  is  said  to  be  always  even  and  general,  without  distinctions  between  the 
various  muscle-groups  (where  would  he  class  hysterical  stupor  with  catalepsy  of 
only  one  arm  ?).  Speech  is  said  not  to  be  more  involved  than  the  other  spheres  ; 
initiative  movements  are  more  aifected  than  reactive  movements,  expressive  move- 
ments scarce,  but  never  totally  missing  ;  especially  the  eye  will  always  follow  the 
speaker  (?) ;  moreover,  the  specific  motor  symptoms  of  the  simple  motihty-psychosis 
are  absent. 

Compulsive  speech,  syncopal  states,  hypochondriacal  palsies  (in  limited  muscle 
groups),  psychical  palsies,  and  fixed  contractures  are  considered,  and  a  discussion  of 
the  possible  meaning  and  origin  of  the  motility  symptoms  closes  the  chapter  (which 
is  rather  vague  and  makes  one  conscious  of  the  obscurity  of  this  whole  topic).  Not- 
withstanding this  strictly  observing  attitude  and  keen  disquisition  on  the  facts,  one 
becomes  conscious  of  the  immense  difiiculties  in  the  way  of  a  thorough  understand- 
ing of  psychoses  through  the  mere  analysis  of  the  nature  of  the  symptoms.  A  great 
longing  for  siniplicity  begins  to  clamor  in  us,  and  who  would  not  hail  the  veiy  attrac- 
tive structure  held  out  to  us  by  Kraepelin,  if  it  were  not  for  the  fact  that  clinical 
experience  seems  to  remonstrate  against  simplicity  where  things  are  actually  very 
complex  ? 

For  a  beginner,  Wernicke's  whole  plan  seems,  at  first  sight,  veiy  difiicult  to  grasp. 
Considering  the  small  amount  of  analytical  knowledge  that  is  actually  necessary  to 
do  one's  duty  in  a  hospital  for  the  insane,  such  a  burden  of  puzzles  and  analyses 
would  to  many  appear  overpowering  and  meaningless.  Even  for  one  who  seriously 
tries  to  leara  what  there  is,  without  any  worry  over  the  burden,  the  feeling  is 
pardonable  that  there  seem  to  be  more  names  than  can  be  made  use  of  comfortably 
for  the  distinctions  off'ered.  After  all,  practical  life  is  what  confronts  us.  We_  are 
physicians  to  patients,  and  we  have  a  right  to  say  that  the  use  of  g^eneralizations 
ought  to  have  its  vindication  through  the  help  they  bring  in  specific  instances. 
The  merit  of  Wernicke  lies  in  his  faithful  and  accurate  descriptions,  and  these  place 
him  above  all  reproach  and  question  ;  and  he  certainly  removes  the  blinding  dogma 
of  traditional  nomenclature  from  a  number  of  very  important  facts.  But  his  system 
of  analysis  seems  to  totally  blind  him  to  very  important  issues  which  we  might  well 
begin  to  utilize. 

The  principal  concepts  Wernicke  gives  us  are  :  first  that  of  sejunction.  Its  utility 
is  problematic,  and  it  is  a  mere  transcription  of  derangement  of  a  habit,  of  adequate 
appreciation  of  things  (by  hallucinosis  and  false  interpretations),  of  thought,  reason- 
ing, action  (various  types  of  delusions) ;  second,  that  of  the  divisibility  of  the  topics 


682  MENTAL  DISEASES. 

of  psychic  activity  into  three  topographicahy  outUned  spheres.  _  Both  these  concepts 
seek  favor  under  the  appearance  of  having  something  to  do_  with  ultimate  cerebral 
locaHzation,  but  neither  with  much  hope  of  carrying  conviction.  The  case  is  some- 
what similar  to  that  of  some  other  concepts  of  general  psychopathology,  such  as 
that  of  the  autointoxication  theory  of  so  many  writers.  Purging  and  purifying  the 
blood  have  so  long  been  the  doctor's  chief  rehance  that  the  autointoxication  theoiy 
naturally  flatters  the  mind  of  those  whose  empirical  habit  is  thus  supphed  with  a 
scientific  motive  (to  eliminate  poisons  even  if  there  be  no  evidence  of  poison  in  many 
disorders  in  which  a  purge  may  do  good).  A  gain  in  localization  might  similarly 
please  the  neurologically  inclined  physician,  but  even  there  the  sober  ones  will  ask  : 
Where  is  the  evidence?  There  are,  however,  many  advantages  in  Wernicke's  divi- 
sions, both  as  to  method  and  as  to  results.  What  he  arrives  at  with  his  theories 
appears,  indeed,  to  have  a  good  practical  foundation  ;  but  the  harmony  between  the 
deductions  from  his  theories  and  the  actual  observations  does  not  necessarily  prove 
their  correctness.  However  this  be,  Wernicke's  descriptions  and  analyses  have  at 
least  the  merit  of  being  the  best  we  have  to-day,  and  this  is  not  to  be  forgotten  by 
the  critic. 

Ziehen,  who  has  conceived  a  definite  psychology  of  his  own,^  naturally  turns  to  it 
for  the  purpose  of  teaching  psychiatry,  because  of  the  love  of  the  student  for  re- 
construction of  the  complex  reality  out  of  a  small  number  of  elements  which  can  be 
remembered  a  tolerable  length  of  time.  Wernicke  creates  his  psychology  with  the 
needs  of  the  neurologist  and  localizer  in  mind.  But  he  does  more.  The  standard 
emotions  of  exaltation  and  sadness  are  correctly  supplemented  by  those  of  anxiety, 
perplexity,  and  irascibility ;  the  mechanisms  for  adequate  psychic  adaptation  or 
plasticity  are  also  very  justly  divided.  Those  concerning  the  outside  world,  and  our 
relations  to  it,  are  open  to  many  illusions  and  false  interpretation  even  in  ordinary 
life,  and  this  is  easily  increased,  by  defective  states  of  the  sense  organs  and  by  de- 
fect in  our  critical  elaboration  (allopsychic  disorientation),  into  deliria._  Those  con- 
cerning our  own  personality,  character,  etc.,  are  more  apt  to  be  disturbed  from 
other  sources  ;  they  are  very  delicate  and  their  derangement  of  tremendous  impor- 
tance for  our  entire  conduct  (autopsychic  disorientation).  Those  concerning  our 
body  are  most  automatic,  and  least  open  to  correction  by  outside  criticism,  and  to  a 
large  extent  resting  on  unconscious  habits  ;  and  their  disturbance  (somatopsj'chic 
disorientation)  is  apt  to  be  a  sign  of  rather  grave  importance.  It  fiirther  becomes 
quite  obvious  that  many  functions  are  shown  to  be  deranged  in  insanity  which  could 
hardly  fit  into  traditional  psychology,  but  are  properly  put  together  as  preeminently 
motor.  These  points  cover  in  the  main  Wernicke's  attitude.  The  discrepancy 
begins  where  we  see  Wernicke  anxious  to  claim  a  decided  advantage  for  the  close 
limitation  of  a  combination  of  a  few  symptoms  where  the  existence  of  transition- 
forms  shows  so  plainly  that  there  can  be  no  profound  natural  difference.  In  the 
matter  of  relationship  between  mania  and  confiised  mania,  Wernicke  himself  admits 
this.  This  admission  in  one  jjlace  might  have  given  him  a  hint  as  to  the  advantage 
of  a  broader  view.  Again,  under  the  heading  of  akinetic  motility-psychosis,  condi- 
tions seemingly  very  distinct  in  nature  are  ranged  side  by  side,  where  separation 
would  have  added  greatly  to  our  interest. 

In  this  respect  Kraepelin  has  undoubtedly  shown  a  broader  and  more  helpful 
attitude.  The  great  question  of  the  relatives  of  the  patients  and  of  the  physician 
himself  is  undoubtedly, '  'What  will  be  the  fate  of  the  patient  ?  " 

Kraepelin  has  put  together  what  is  most  helpful  for  this  question.  Wernicke 
makes,  however,  some  severe  comments  on  the  freedom  which  Kraepelin  takes  in 
shaping  his  dogma  regardless  of  difficulties. 

What  do  his  contemporaries  say  concerning  dementia  f 

We  have  seen  that  Ziehen  records  about  6  per  cent,  of  mania  and  melancholia 
(in  the  narrow  definition  which  he  gives  these  forms)  as  terminating  in  secondary 
dementia.  In  acute  hallucinatory  paranoia  (the  large  body  of  acute  psychoses, 
according  to  Ziehen)  at  least  15  per  cent,  terminate  this  waj' at  once,  and  this  is 
brought  into  connection  with  the  accounts  of  cell  and  fiber  degeneration  in  these 
cases.  Yet  even  Ziehen  says  in  his  second  edition  that  the  diagnosis  of  secondary 
dementia  was  made  altogether  too  frequently  formerly.  "Careful  observation  has 
shown  that  in  many  cases  which  formerlj'  were  counted  with  secondary  dementia  the 
intellectual  defect  is  not  secondary,  but  accompanies  the  psj^chosis  from  the  begin- 
ning. In  this  case  it  is  not  a  secondary  dementia  after  a  functional  psychosis,  but  a 
primarj'  'defect-psychosis,'  simulating  in  the  beginning  a  functional  psychosis. 
Confusion  with  hebephrenic  dementia  is  especially  easy,  for  its  initial  stage  often 


A  KEVIEW  OF  RECENT  PROBLEMS  OF  PSYCHIATRY.  683 

presents  the  picture  of  a  melunchulia,  ur  mania,  or  halluciiiatuiy  }iaraii(jia.  To  de- 
termine whether  an  intellectual  defect  has  existed  from  the  start  is  often  ex- 
tremely difficult.  One  has  to  depend  on  the  frequently  unreliable  history  furnished 
by  relatives,  and  moreover  the  testing  of  intelligence  is  made  extremely  difficult  by 
coexisting  disorders  of  affect.  Without  anamnesis  or  observation  from  the  on.set  of 
the  disease,  the  diagnosis  is  frequently  quite  impossible.  One  can  only  say  that 
pronounced  tendency  to  stereotyjiies  and  perseveration  and  to  catatonic  conditions  is 
somewhat  more  frequent  with  dementia  hebephrenica. " 

In  his  first  edition  lie  merely  admitted  "  hebeijhrene  Modijicationen  "  of  mania, 
melancholia,  etc.,  and  saw  in  the  symptoms  only  a  pathological  caricature  of  certain 
traits  which  belong  to  normal  puberty.  Hebephrenic  dementia  did  not  exist.  In 
the  second  edition  "dementia  hebephrenica  or  hebephrenia  is  a  defect-psychosis 
which  begins  at  puberty  and  is  characterized  by  a  progressive  primary  defect  and 
several  characteristic  accompanying  symptoms  (apathy,  stereotypy,  inhibitions, 
etc.)."  He  describes  a  simple  form,  a  paranoid  variety,  a  catatonic  variety,  and  a 
circular  variety  (with  cycles  of  one  to  four  week),  and  mentions  the  decided  ten- 
dency to  remissions  resembling  complete  recovery  which  create  the  false  impression 
that  the  actual  hebephrenia  has  been  preceded  by  another  psychosis,  such  as 
melancholia.  He  finds  these  cases  much  more  frequent  in  Holland  than  in  Jena. 
He  limits  their  occurrence  to  the  period  of  puberty,  and  exceptionally  in  retarded 
puberty  up  to  the  twenty-fifth  year,  and  states  explicitly  that  those  who  claim  to 
have  seen  cases  of  dementia  prsecox  even  in  the  sixth  decade,  probably  confused  it 
with  dementia  secundaria,  dementia  traumatica,  etc.  ^  His  remarks  on  differential 
diagnosis  are  very  interesting,  too,  for  their  strict  adherence  to  the  meaning  of 
words,  where  others  would  have  taken  a  larger  view  of  the  facts.  Catatonia  is 
maintained  as  a  "  rare  disease ' '  with  four  stages — a  melancholic,  a  maniacal,  a 
stuporous  one,  and  one  of  secondary  dementia.  One  of  the  first  three  stages  may 
be  absent.  It  may  occur  at  any  age.  Recoveiy  is  rare  (evidently  here  Ziehen  does 
not  accept  Kahlbaum's  views).  Many  cases  described  as  such  are  instances  of  the 
catatonic  form  of  chronic  hallucinatory  paranoia  and  of  dementia  hebephrenica. 
Ziehen  has  ' '  seen  only  two  cases  in  which  the  intellectual  defect  certainly  appeared 
only  secondarily,  and  which  coiTesponded  to  the  definition  of  Kahlbaum  in  course 
and  symptoms,  without  any  focal  disease  found  at  the  autopsy."  He  mentions  one 
perfectly  typical  case,  in  which,  however,  he  found  a  partial  old  softening  in 
the  region  of  the  arteria  cerebri  anterior,  of  possibly  traumatic  origin,  and  mentions 
the  frequency  of  catatonic  symptoms  in  general  paralysis,  and  in  senile,  traumatic, 
and  epileptic  dementia,  etc.  In  the  first  edition  the  catatonic  stereotyped  attitudes 
and  movements  are  said  to  occur  chiefly  in  melancholia  attonita,  paranoia  hallu- 
cinatoria,  and  any  form  of  dementia.  Considering  the  fact  that  Ziehen  was 
originally  an  assistant  of  Kahlbaum,  it  is  remarkable  that  he  does  not  see  the  purely 
theoretical  origin  of  Kahlbaum's  definition  of  four  stages,  in  the  Zeller-Neumann 
theory  of  insanity,  and  the  absolute  freedom  with  which  Kahlbaum  himself  treated 
his  definition.  Kahlbaum  found  the  prognosis  favorable.  Still,  Ziehen  adheres  to 
the  letter  rather  than  to  the  meaning  of  his  first  master. 

A  more  conventional  position  is  taken  in  this  matter  by  Mendel  in  his  recent 
"Leitfaden  der  Psychiatric"  (1902).  He  still  holds  to  the  ordinaiy  primary  psy- 
choses and  secondary  dementias  :  delirium  hallucinatorium  with  80  per  cent,  (in 
asylums  only  45  percent.)  of  recoveries,  mania  (no  definite  percentages  given  beyond 
the  statement  that  80  per  cent,  recover),  melancholia  (hypomelancholia  always  re- 
covered from,  while  only  60  per  cent,  of  the  real  melancholia  recover) ;  in  circular 
insanity  final  dementia  is  the  exception  ;  in  paranoia  he  admits  a  stadium  dementias 
(without  percentages),  and  in  acute  dementia  recovery  in  80  per  cent.  As  a  special 
form  of  hypochondriacal  melancholia  he  mentions  those  cases  which  rapidly  lead  to 
dementia  under  the  influence  of  puberty  and  constitute  a  large  portion  of  the  cases 
of  hebephrenia  and  catatonia.  A  reference  directs  the  reader  to  the  chapter  on 
etiology,  where  Kraepelin's  dementia  prascox  is  summarized  as  a  "  special  course  of 
such  psychoses  appearing  during  the  period  of  puberty. ' '     Mendel  states  that  2  to 

^  He  does  this  without  inquiring  into  the  possibility  that  there  are  really  cases  at 
that  age  which  are  characteristic  defect-psychoses  from  the  start  ;  and  he  forgets  that 
before  he  admitted  the  "dementia  hebephrenica"  he  made  the  same  blunder  which  he 
now  wants  others  to  coutinne,  simply  because  of  his  narrow  adherence  to  the  name 
"  hebephrenic  "  as  referring  to  age — the  same  trouble  to  which  we  presently  refer  con- 
cerning catatonia. 


684  3IENTAL  DISEASES. 

3  per  cent,  of  the  patients  in  Berlin  belong  to  this  class.  Yet  he  does  not  give  the 
group  a  special  place  in  his  "special  psychiatry."  Furthermore,  in  the  general 
portion  of  his  book,  in  the  chapter  on  the  outcome  of  psychoses,  he  gives  a  descrip- 
tion of  paranoia  secundaria  ("developing  from  delirium  hallucinatorium,  rnania,  or 
melancholia"),  acquired  dementia,  agitated  dementia  or  demented  confusion  (the 
outcome  of  melancholia,  mania,  or  paranoia),  and  apathetic  dementia.  "The 
question  why  in  one  case  a  functional  psychosis  terminates  in  recovery,  and  in  another 
in  incurable  dementia,  can  not  be  answered  to-day.  Experience  shows  that  especially 
those  functional  psychoses  which  appear  at  puberty,  and  in  which  there  is  marked 
heredity,  pass  frequently  and  rather  rapidly  into  dementia  (dementia  praecox,  in 
which  Kraepelin  distinguishes  a  hebephrenic,  catatonic,  and  paranoid  form). 

Wernicke's  standpoint  forbids  the  recognition  of  a  hebephrenia  because  he  will 
not  admit  any  types  as  identical  which  have  not  a  uniform  symptom-complex.  We 
have  seen  that,  even  in  general  paralysis,  he  speaks  of  an  ' '  etiological  group  ' '  oi 
paralytic  psychoses.  We  find,  indeed,  that  he  has  given  up  Kahlbaum  and  Becker's 
hebephrenia  as  a  disease-type.  Clinical  experience  has  made  him  abandon  it  more 
and  more,  and  to-day  he  can  only  stand  for  the  very  considerable  importance  of 
"  hebephrenic  etiology. "  He  accepts  Kahlbaum' s  "  heboid  "  ^  as  a  specific  form  of 
puberty-psychosis  only,  a  moral  auto-psychosis,  i.  e. ,_  a  relatively  rare  type  not  ac- 
cepted in  any  text-book  except  partially  in  Wernicke's. 

In  the  lecture  on  acute  autopsychoses  he  gives  an  account  of  so-called  alternat- 
ing 23ersonality  chiefly  on  hysterical  or  epileptic  or  alcoholic  degenerative  founda- 
tion, and  of  those  cases  of  reasoning  mania,  which,  according  to  French  authors, 
recur  with  always  the  same  scheme  and  an  often  surprisingly  uniform  plan  of 
action  ;2  and  of  certain  cases  of  periodic  alcoholism.  ^  This  moral  autopsychosis  in 
its  climacteric  form  is  mostly  of  unfavorable  prognosis,  and  in  its  senile  form  probably 
always  a  transition  toward  senile  dementia,  but  in  its  hebephrenic  form  relatively 
curable.  The  instance  he  gives  is  that  of  a  girl  with  transitory  loss  of  all  discipline, 
feeling  of  responsibility  and  modesty,  a  tendency  to  obscenity  but  total  absence  of 
impulsive  talking,  flight  of  ideas,  and  motor  unrest.  Within  three  years  there 
followed  three  recurrences,  and  in  the  interval  slight  depressions.  One  might  have 
thought  of  circular  insanity,  but  that  would  not  do,  ' '  if  one  desired  to  cling  to  the 
definition  of  it  as  a  regular  alternation  between  manic  and  melancholic  states."  The 
leveling  down  of  the  dominant  moral  concepts  "with  the  not  infrequently  total 
absence  of  intellectual  disorder ' '  is  indeed  similar  to  what  occurs  in  mania  ;  but  the 
other  cardinal  symptoms  of  mania  are  absent,  and  Wernicke  is  nowhere  willing  to 
admit  the  "' formes  frnstes.^^  Kahlbaum' s  cases  are  certainly  noteworthy,  and  I  am 
able  to  i)oint  to  several  such  cases  of  my  own  which  had  a  far  more  undecided  position 
between  Kraepelin' s  manic-depressive  insanity  and  his  dementia  praecox  than 
Wernicke's  instance. 

In  the  typical  "heboid"  (the  exaggeration  of  features  of  puberty)  Weraicke 
adds  to  Kahlbaum' s  description  the  symptoms  of  onerous  .sensations,  onerous 
ideas,  and  hypochondriacal  sensations  as  constant  accompaniments.  We  should 
refer  to  this  gi'oup  again  in  a  discussion  of  '"'  formes  frvstes,'^  or  of  vague  types. 

As  rather  characteristic  of  hebephrenic  etiology  Wernicke  mentions  ' '  hebe- 
phrenic expansive  autopsychosis,"  a  "  primary  paranoia,"  which  passes  rapidly  into 
attonity  and  dementia.  Next  in  frequency  he  finds  motility-psychoses,  especially 
the  akinetic  form.  Very  characteristically  he  says  that  the  well-known  tendency  of 
akinetic  motility-psychoses  to  pass  into  dementia,  as  well  as  the  erroneously  claimed 

1  "Allg.  Zeitschrift  fiir  Psychiatric,"  vol.  xlviii. 

2  An  illustration  is  given  of  a  clerk  who  periodically  assumed  the  role  of  a  physi- 
cian and  committed  apparently  shrewd  embezzlements,  but  always  in  the  same  way  : 
this  patient  finally  ended  in  epileptic  dementia.  The  term  reasoning  mania  and  the 
term  moral  insanity  have  gradually  lost  the  meaning  they  originally  had.  and  they  are 
incorrectly  applied  to  what  the  meaning  of  the  word  seems  to  imply  to  the  modern 
mind,  unless  one  return  to  the  old  sources ;  a  good  illustration  of  the  power  of  word 
over  sense  of  accuracy. 

^  The  "pathological  intoxication."  however,  is  classed  with  the  true  dream-states, 
such  as  most  of  the  pre-  and  post-epileptic  psychoses.  (I  mention  this  to  give  another 
instance  of  Wernicke's  respect  for  the  symptom-complex  notwithstanding  the  fact  that 
the  essential  cause  or  condition  is  the  same  for  several  types  of  disorders.)  Wernicke 
describes  a  type  of  so-called  acquired  moral  insanity  (in  the  modern  sense  of  the  word  ; 
see  an  account  of  its  history  in  my  article  in  Baldwin's  "  Dictionary  of  Psychology." 
vol.  ii). 


A  REVIEW  OF  RECENT  PROBLEMS  OF  PSYCHIATRY.  685 

tendency  to  recurrences,  might  in  part  be  referable  to  this  etiological  relation  (/'.  e. , 
the  origin  during  puberty).  Yet  he  knows  of  cases  of  akinetic  niotility-psychoses 
during  puberty  which  recovered  completely  and  permanently.  "  Hence  the  unfav- 
orable prognosis  which  Kraepelin  gives  in  tliese  cases  does  not  even  hold  without 
exception  for  the  cases  during  puberty."  Another  frequent  picture  during  puberty 
is  the  hypochondriacal  anxiety-psychosis,  which  may  remain  abortive,  or  develojj 
further,  and,  jierhaps  after  an  intercurrent  phase  of  "total  sensory  psychosis" 
(=  delirium),  with  a  trend  of  fantastic  hypochondriacal  persecution,  pass  into  a  very 
characteristic  hebephrenic  dementia  such  as  Kahlbaum  describes.  Certain  acute  at- 
tacks of  "weakness  of  association  with  autopsychic  and  allopsychic  defects,  but 
without  any  signs  of  irritation  on  tlie  motor  side,"  in  young  girls,  recovered  after  a 
prolonged  paranoic  state.  Considering  the  relative  difficulty  in  getting  their  atten- 
tion, they  have  a  surprising  grasp  on  what  they  observed.  These  cases,  too, 
although  recoverable,  seem  to  be  on  a  hebephrenic  basis. 

1  mention  these  with  some  detail  because  we  need  the  facts  in  our  comparison 
with  Kraepelin's  step  in  advance.  Wernicke  does  not  say  (any  more  than  do  Ziehen 
or  Mendel)  just  in  what  way  puberty  is  accountable  as  a  factor  in  etiology.  He 
attacks  "hebephrenia"  in  its  original  sense  (as  a  feature  of  puberty),  whereas 
dementia  prcccox  in  Kraepelin's  sense  refers  more  to  the  fact  of  a  special  form  of 
deterioration  and  not  so  much  to  the  age  of  onset.  Wernicke  sees  the  characteristic 
feature  of  hebephrenic  etiology,  not  in  the  childish  manner  and  silly  ways  that 
appear  quite  natural  in  dementia  at  this  period  of  life,  but  in  the  tendency  to  un- 
favorable outcome  (or,  where  they  end  in  recovery,  in  the  tendency  to  temporary  symp- 
toms of  defect).  He  sees  other  characteristics  in  the  predilection  for  certain  disease- 
pictures,  which,  however,  do  not  belong  exclusively  to  the  period  of  puberty ;  in  a 
tendency  to  recurrences,  and  where  they  have  a  chronic  course,  to  exacerbations,  so 
that  the  most  acute  attacks  occur  as  intercurrent  episodes.  Moreover,  most  of  the 
acute  cases,  and  in  part  also  those  of  chronic  development,  take  their  course  as  com- 
pound psychoses,  i.  e. ,  at  successive  periods  they  produce  totally  different  disease-pic- 
tures. He  refers  to  a  case  which  he  demonstrated  first  as  an  affective  melancholia, 
in  the  following  semester  as  hyperkinetic  motility-psychosis,  and  finally  as  a  condition 
of  pure  defect  in  deep  dementia,  and  he  describes  how  vivid  the  face  looked  in  con- 
trast to  the  emptiness  of  mind,  in  distinction  to  what  happens  in  general  paralysis. 
This  whole  case  is  an  instance  in  point  of  the  difficulty  of  that  "prognostic  diagnosis  " 
which  Kraepelin  makes  so  attractive  an  aim  of  psychiatry. 

To  complete  this  review,  I  must  refer  to  Wernicke,  page  544,  where  the  forms 
of  acquired  dementia  are  treated  connectedly.  After  a  brief  description  of  its 
effects  of  traumatism  (in  which  he  admits  the  possibility  of  a  progressive  degenera- 
tive process  started  by  the  trauma),  of  the  mental  aspect  of  multiple  sclerosis,  of 
lues  cerebri,  of  meningitis,  he  says  :  "At  the  period  of  puberty  one  sometimes  ob- 
serves a  dementia  which  may  develop  relatively  rapidly  and  which  may  become 
very  deep  without  being  accompanied  by  essential  psychotic  symptoms  of  another 
kind.  In  other  cases  such  a  primary  degenerative  dementia,  preceded  by  attacks 
of  severe  headache,  develops  at  puberty,  with  delusions  of  reference  of  a  harmless 
character,  especially  autopsychic  delusions  of  reference  (what  the  patient  sees  or 
hears  is  interpreted  as  having  some  reference  to  his  thoughts  ;  or  hallucinations  are 
interpreted  in  this  way ;  the  patient  has  the  feeling  that  his  thoughts  are  spoken 
aloud,  etc.).  Cases  of  recovered  primary  dementia,  subacute  in  development,  and 
outside  of  the  period  of  puberty  have  come  to  my  notice  several  times ;  but  I 
should  prefer  to  class  them  with  depressive  melancholia,  from  which  they  are  diffi- 
cult to  distinguish  clinically."  Apart  from  senile,  epileptic,  post-apoplectic,  alco- 
holic, and  paralytic  dementia,  there  are  "  certain  definite  clinical  forms  of  psychoses 
which  show  a  tendency  to  terminate  in  dementia,  if  they  do  not  recover.  In  this 
respect  all  forms  of  motility-psychoses,  especially  the  akinetic  type,  are  not  so  veiy 
far  from  the  paralytic  psychoses.  In  the  description  of  the  special  types  (paralytic, 
post-apoplectic,  epileptic,  alcoholic,  hebephrenic,  senile)  he  says :  ' '  Hebephrenic 
dementia  has  the  general  marks  of  an  immature  state  of  development  correspond- 
ing to  the  age  of  puberty.  Hence  the  childish  and  silly  behavior  of  these  patients 
especially  insisted  upon  by  Kahlbaum  and  Hecker.  Next  to  this,  I  should  like  to 
lay  stress  upon  pronounced  thoughtlessness  or  mental  laziness  as  specific  features  of 
hebephrenic  dementia.  This  is  often  shown  in  a  very  characteristic  manner.  The 
patients  answer  questions  hit  or  miss  without  noticing  their  self-contradictions.  _  The 
same  question  first  answered  with  yes,  may  be  later  answered  with  no,  or  with  a 
most  general  phrase.  Gradually  in  the  course  of  the  examination  an  unmistakable 
annoyance  at  being  forced  to  mental  exertion  is  exhibited,  and  on  questioning  one 


686  MENTAL  DISEASES. 

may  at  times  learn  that  thinking  tires  tiie  patient.  A  turning  away  or  the  excla- 
mation, "  let  me  alone  !  "  or  even  at  times  an  outbreak  of  violence,  puts  an  end  to 
the  interview.  The  attention  of  these  patients  is  difficult  to  gain  and  especially 
difficult  to  hold  for  the  purpose  of  examination.  The  form  of  observation  is  some- 
times surprisingly  good  if  iudged  by  the  patient's  remembrance  of  casual  incidents. 
One  sometimes  experiences  surprises  with  these  patients  inasmuch  as  they  casually 
betray  fragments  of  knowledge,  for  instance,  of  languages  or  other  acquired  material 
of  memory  for  which  one  searches  in  vain  in  a  systematic  examination.  The  facial 
expression,  although  at  times  more  or  less  changed,  usually  remains  much  more 
vivid  than  might  be  expected  from  the  degree  of  dementia  (an  instance  in  Heft  2, 
case  28,  of  the  "  Krankenvorstelungen  ").  The  marks  of  mannerisms  and  oddity 
of  expression  are  in  most  cases  well  defined,  as  is  easily  intelligible  from  the  age  of 
the  patients ;  but  according  to  my  experience  it  is  not  as  characteristic  for  hebe- 
phrenia as  the  intellectual  laziness  mentioned  first. " 

A  special  ""secondary  dementia''  is  not  described  by  him.  But  the  admission 
of  primary  dementia  in  the  sense  of  Kraepelin  makes  one  ask  :  Why  not  recognize 
and  extend  the  principle  ?  These  cases  share  the  fate  of  the  ' '  paralytic  psychosis. ' ' 
Among  Wernicke's  descriptions  one  looks  in  vain  for  the  simple  demented  forms  of 
general  paralysis,  whereas  they  form  the  background  of  the  whole  picture  of  the 
disease  as  furnished  by  Kraepelin. 

After  what  we  have  learned  of  Ziehen's,  Mendel's,  and  Wernicke's  views,  on 
"secondary  dementia,"  let  us  start  again  from  the  disorder  that  is  commonly  so  de- 
nominated by  the  average  hospital  physician.  In  the  statistics  published  by  the 
Lunacy  Commission  of  the  State  of  New  York  we  find  the  following  table  : 

Since  October  i,  1888. 

Admitted.  Recovered.        Died. 

Mania,  acute  delirious 150  24  102 

Mania,  acute         9,816  4,109  1,293 

Mania,  recurrent 1,004  436  94 

Mania,  chronic 4,262  208  1,249 

Melancholia,  acute 15,400  5,110  2,013 

Melancholia,  simple 547  192  23 

Melancholia,  chronic 4,384  289  1,423 

Alternating  (circular)  insanity 138  9  6 

Paranoia    . ' 674  24  43 

General  paralysis 4,128  1  3,113 

Dementia,  primary 1,295  214  488 

Dementia,  terminal 13,170  107  7,733 

Epilepsy  with  insanity 2,073  42  887 

Imbecility  with  maniacal  attacks    ....    1,097  10  147 

Idiocy 145  .    .  33 

Not  insane  i      473  .    .  13 

Unclassified 937 

Total 59,693  10,775  18,660 

This  table  shows  that  a  relatively  large  number  of  cases  figures  among  the  acute 
psychoses  which  would  be  placed  among  the  chronic  or  compound  psychoses  of  the 
above-mentioned  writers,  if  we  assume  that  the  recovery  rate  is  about  the  same  the 
world  over,  and  not  worse  in  New  York.  Of  the  acute  psychoses  as  Ziehen  recog- 
nizes them,  at  least  70  per  cent,  recover ;  of  the  combined  acute  manias  and  mel- 
anchohas  in  the  State  of  New  York,  only  36. 5  per  cent. 

Leaving  utterly  out  of  the  question  the  problem  of  disease-entities  and  treating 
the  congregate  mass  of  one  hundred  consecutive  admissions  to  a  hospital  purely 
from  the  point  of  view  of  symptom-complexes,  and  of  the  final  outcome,  we  may 
ask  :  In  how  many  cases  was  it  possible  to  predict  with  certainty  the  outcome  ?  To 
what  extent  do  the  discrepancies  point  to  insufficient  inquiry  into  the  facts  ?  And 
to  what  extent  is  the  satisfaction  with  vague  terms  at  the  bottom  of  the  indiff"erence 
to  facts? 

As  a  matter  of  fact,  every  alienist  of  experience  will  point  to  patients  in  whom 
secondary  dementia  can  be  foretold.  Unfortunately,  reasons  are  but  rarely  given. 
"This  is,  however,  one  of  the  best  methods  of  training  in  psychiatry  :  To  formulate 
in  exact  terms  the  facts  which  guide  us  in  prognosis.,  to  give  the  reasons  why  they  do 
so,  and  to  test  the^e  reasons  on  the  ha,sis  of  the  final  results. 

^  Includes  cases  of  alcoholism,  drug  habit,  etc. 


A  REVIEW  OF  RECENT  PROBLEMS  OF  PSYCHIATRY.  687 

lo  general  paralysis  we  can  say  that  tliere  is  a  certain  neurological  status  com- 
bined with  a  definite  mental  picture ;  that  it  points  empirically  to  what  may  be 
called  a  diffuse  myelo-encephalitis  ;  that  the  type  of  distribution  and  the  depth  of 
the  symptoms  furnish  evidence  of  a  certain  loss  ;  and  that  empirically  on  such  a 
basis  a  number  of  eventualities  are  to  be  expected. 

In  delirium  tremens  we  have  a  certain  standard  combination  of  symptoms, 
mental  and  physical,  and  in  drawing  our  conclusion  we  consider  these  facts  in  the 
light  of  our  experience — the  general  make-up  of  the  patient,  and  the  possibility  of 
a  symptomatic  delirium  tremens  (a  phase  of  general  paralysis,  etc.). 

In  acute  excitement  we  have  our  psychic  and  physical  symptom-complexes  and 
fragments  of  the  etiological  constellation  to  go  by.  In  a  fair  number  of  the  cases  we 
will  predict  recovery  ;  in  others  we  remain  in  doubt ;  in  yet  others  we  predict  an  un- 
favorable outcome — death,  or  imperfect  recovery,  or  danger  of  relapses  or  recurrences, 
or  secondary  paranoia,  or  secondaiy  dementia. 

The  question  now  comes  up — and  it  has  been  answered  in  the  affirmative  by 
Kraepehn  :  Are  the  signs  which  determine  a  good  or  a  bad  prognosis  fundamental 
enough  to  build  on  them  a  grouping  of  mental  diseases,  which  would  be  more  natural 
than  the  present  hazy  plan  or  the  more  ambitious  psychological  schemes  ? 

The  clinical  signs  are  of  varying  value.  The  nearer  they  are  to  the  funda- 
mental i^art  which  is  diseased,  the  more  direct  is  their  bearing ;  the  more  accidental 
they  are,  the  plainer  their  nature  as  mere  circumstantial  evidence,  and  the  less  con- 
vincing the  claims  of  decisiveness.  The  symptoms  are  empirical  and  must  stand  the 
test  of  experience  in  order  to  command  our  attention.  They  must  be  judged  in 
every  case  for  what  they  are  worth.  Yet  when  we  look  at  the  average  hospital  record 
or  at  the  average  text-book  description  we  fail  to  find  the  necessaiy  helps  for  the 
distinctions  which  Kraepelin  makes. 

Wernicke's  descriptions  make  a  laudable  exception,  and  in  many  respects  they  are 
more  helpful  methodically  and  less  dogmatic  than  Kraepelin' s  composite  pictures. 
We  have  seen  that  his  mania,  confused  mania,  and  in  part  the  hyperkinetic  motility- 
psychosis  form  the  excited  phases  of  manic-depressive  insanity,  and  affiective  melan- 
cholia and  certain  cases  of  depressive  (akinetic)  melancholia  the  depressive  phases. 
The  mixed  phases  are  noticed  by  Kraepelin  only.  In  hyperkinetic  and  akinetic  states 
in  which  access  to  the  inner  life  of  the  patient  is  difficult,  and  in  the  acute  delusional 
and  delirious  states,  a  prognostic  diagnosis  appears  much  more  problematic  if  based 
on  the  symptoms  only.  There  is,  however,  so  much  harmony  in  what  has  been 
achieved  by  Kraepelin  and  Wernicke  that  we  may  look  to  the  recent  products  of 
psychiatric  work  with  the  feeling  that  the  confusion  of  words  and  the  appearance  of 
abstruseness  will  cease  more  and  more  in  a  measure  as  we  keep  to  observation  of 
actual  cases,  and  records  which  cover  the  useful  distinctions. 

Viewing  all  these  ways  of  getting  at  the  facts  of  psychiatry,  we  cannot  avoid  the 
conviction  that  much  of  what  floats  in  the  air  as  solid  tradition  is,  after  all,  very  far 
from  a  firm  foundation,  and  even  far  from  doing  justice  to  what  we  think  and  do  in 
actual  contact  with  cases.  Much  of  it  is  due  to  an  attempt  to  appear  connected, 
orderly,  and  reasonable,  in  lecturing  and  writing,  but  it  is  apt  to  prove  a  real  obstacle 
to  progress  in  our  work.  If  these  traditional  ideas  are  taken  as  suggestions,  they  are 
helpful ;  if  taken  as  laws,  they  are  temptations  for  a  healthy  law-breaking  instinct, 
or  they  become  harmiul  chains.  In  closing  this  review  there  are  two  warnings  to 
which  the  reader's  attention  should  be  called.  The  first  is  :  Beware  of  definitions 
which  one  is  tempted  to  make  from  the  sound  of  the  words  !  Melancholia,  dementia 
praecox,  catatonia,  represent  totally  diff"erent  trains  of  thought  in  the  various  writers. 
The  second  warning  is  :  Beware  even  of  the  definition  given  by  any  special  author  ! 
It  is  better  to  study  the  histories  of  his  cases,  because  his  definition  may  unconsciously 
render  the  trend  of  words  as  he  is  accustomed  to  use  them.  It  is  not  too  much  to 
say  that  it  would  often  be  difficult  for  these  authors  themselves  to  determine  ex- 
actly where  they  stand  in  regard  to  some  of  the  matters  still  in  dispute.  Their  cases 
are  more  truthftil,  actual,  and  clear — when  described  in  toto — than  any  attempt  at  a 
general  psychopathology  could  be  at  the  present  time. 

This  review  is  necessarily  merely  a  fragment  of  what  occupies  modem  psychiatry, 
and  fully  intelligible  in  its  bearing  only  to  those  who  study  psychiatry  with  the  help  of 
methods  unfortunately  too  long  neglected  in  our  hospitals.  Under  the  influence  of 
pressure  for  financial  results,  and  owing  to  the  lack  of  centers  for  psychiatry  in- 
struction, very  little  material  is  collected  in  this  country  on  which  to  bring  the 
questions  of  the  day  to  a  test. 

Psychiatry  is  the  description  and  analysis  of  diseases  which  take  months  and 
years  for  their  evolution,  and  which  require  careful  records  of  conscientious  and 


688  3IENTAL  DISEASES. 

methodical  observations  in  order  to  replace  impressionist  methods  by  an  approxima- 
tion to  methods  of  precision.  In  this  direction  the  above  abstracts  will  certainly  be 
suggestive.  The  review  has,  I  hope,  demonstrated  that  there  are  many  questions 
about  our  patients  which  the  average  work  on  psychiatry  does  not  attempt  to 
answer,  but  for  which  good  methods  of  analysis  present  helps.  It  has,  I  hope, 
convinced  the  reader  that  we  need  less  discussions  of  generalities  and  more  records  of 
well-observed  cases,  and  especially  records  of  lifetimes,  not  merely  snatches  of  pic- 
turesque symptoms  or  transcriptions  of  the  meaning  of  traditional  terms.  It 
includes,  as  well  as  can  be  done  in  so  little  space,  the  chief  standpoints  and  principles 
of  work  of  the  most  productive  pioneers  of  the  day,  and  it  will  encourage  many 
a  reader  to  go  to  the  originals,  and  say  where  to  find  things.  It  would  seem  that 
the  time  is  not  very  far  distant  when  the  traditional  headings  of  chapters  in  our 
text-books  will  change  rather  fundamentally,  and  to  the  great  advantage  of  the 
student  and  practitioner. 


CHAPTER  II. 
GENERAL  ETIOLOGY  OF  INSANITY. 

The  proportion  of  the  insane  to  normal  individnals  may  be  stated 
to  be  about  1  to  300  of  the  population,  though  this  proportion  varies 
somewhat  within  narrow  limits  among  different  races  and  countries.  It 
is  probable  that  the  intemperate  use  of  alcohol  and  drugs,  the  spread- 
ing of  syphilis,  and  the  overstimulation  in  many  directions  of  modern 
civilization  have  determined  an  increase  difficult  to  estimate,  but  never- 
theless palpable,  of  insanity  in  the  present  century  as  compared  with 
past  centuries. 

The  amount  of  such  increase  might  easily  seem  to  be  large,  on  super- 
ficial examination,  because  of  the  imperfection  of  census-taking  in  the 
past,  the  accumulation  of  the  chronic  insane,  and  in  new  communities 
the  constant  uj)building  of  new  asylums. 

Sex. — As  regards  sex,  women  and  men  are  about  equally  affected, 
for  the  particular  etiological  factors  determining  insanity  in  the  one 
(such  as  the  puerperal  period,  the  menopause,  etc.)  are  evenly  balanced 
by  the  special  causes  acting  upon  the  other  (struggle  for  existence, 
drunkenness,  syphilis,  etc.),  and  both  sexes  are  about  alike  in  their  sus- 
ceptibility to  the  two  great  etiological  elements  in  alienation  of  the  mind 
— heredity  and  mental  or  bodily  strain. 

Age. — The  question  of  age  is  of  great  importance  in  a  study  of  the 
etiology  of  insanity.  While  individuals  are  liable  to  mental  aberration 
at  any  age,  yet  there  are  particular  periods  of  life  characterized  by 
special  vulnerability.  In  general,  it  may  be  said  that  this  vulnerability 
is  greatest  in  women  between  the  ages  of  twenty-five  and  thirty-five, 
and  in  men  between  twenty  and  fifty,  for  it  is  at  middle  age  that  we 
find  the  maximum  accumulation  of  etiological  factors.  But  there  are 
physiological  epochs  that  influence  markedly  the  line  of  psychic  mor- 
bidity, and  these  are  the  periods  of  puberty  and  adolescence  (fourteen  to 
twenty  years),  that  of  genital  involution  in  women  (forty-five),  and  that 
of  senile  involution  (sixty  to  seventy  years). 

But  the  chief  factors  in  the  causation  of  insanity  may  be  summed  up 


GENERAL   ETIOLOGY  OF  INSANITY.  689 

in  two  words — heredity  and  strain.  Tlie  f(jrmer  is  responsible  for  in- 
stahilitv  of  tlie  nervous  system,  the  hitter  is  multiform  in  eharacter, 
comprising-  all  of  the  stresses,  physical  and  mental,  direct  and  Indirect, 
autochthonous  and  environmental,  which  may  undermine  the  nervous 
constitution  and  bring  it  to  its  point  of  collapse. 

Heredity. — In  determining  the  factor  of  heredity  we  must  not  be 
content  with  ascertaining  the  existence  of  psychoses  in  the  ascendants, 
but  must  seek,  by  careful  interrogation  of  various  members  of  the  family, 
for  some  of  the  hereditary  equivalents,  such  as  epilepsy,  chorea,  hys- 
teria, neurasthenia,  somnambulism,  migraine,  organic  diseases  of  the 
central  nervous  system,  criminal  tendencies,  eccentricities  of  character, 
drunkenness,  etc.,  for  these  equivalents  are  interchangeable  from  one 
generation  to  another,  and  are  simply  evidences  of  instability  of  the  ner- 
vous system.  It  is  the  unstable  nervous  organization  that  is  inherited, 
not  a  particular  neurosis  or  psychosis,  and  it  must  be  our  aim  in  the 
investigation  of  the  progenitors  to  discover  the  evidence  of  this. 

That  the  statistics  of  insanity  as  regards  heredity  are  often  faultily 
gathered  is  too  well  known.  In  the  first  place,  the  recorder  of  the 
history  of  a  patient  frequently  neglects  to  extend  his  inquiry  far  enough 
to  include  all  of  the  transmissible  psychoneuroses,  and,  in  the  second,  the 
relatives  are  prone  to  conceal  any  supposed  hereditary  taint  in  the 
family.  Here,  for  example,  is  a  table  prepared  by  the  Lunacy  Commis- 
sioners, showing  the  causes  of  insanit}^  in  136,478  admissions  to  asylums 
in  England  and  AVales,  in  which  I  find  the  item  "  hereditary  influence 
ascertained  "  20.5  per  cent.  Surely,  so  small  a  figure  does  not  represent 
the  true  proportion  of  heredity  as  an  etiological  factor  ! 

It  will  take  many  decads  of  much  more  careful  compilation  of  his- 
tories to  establish  the  actual  ratio,  but  we  shall  attain  nearer  to  the  facts 
year  by  year. 

Xo  one  has  better  formulated  the  principles  of  heredity  in  relation 
to  insanity  than  Mercier,i  who  points  out,  among  other  things,  that, 
besides  the  importance  of  the  direct  transmission  of  an  unstable  nervous 
system,  there  is  another  law  of  heredity,  which  is  known  as  the  law  of 
sanguinity.  Two  parents  may  be  perfectly  stable  and  have  normal  organ- 
isms, and  yet  produce  offspring  with  unstable  and  abnormal  nervous 
constitutions,  because  of  the  unsuitability  of  the  sexual  elements  of  the 
parents  to  each  other.  The  perfect  organization  of  the  progeny  is  the 
result  of  three  factors — the  quality  of  the  germ  (which  l^rings  matter), 
the  quality  of  the  sperm  (which  brings  force),  and  the  suitability  of  the 
one  to  the  other. 

The  laws  of  heredity  as  they  relate  to  insanity  may  be  summarized 
briefly  as  follows  :- 

1.  The  child  tends  to  inherit  every  attribute  of  both  parents. 
.  2.   Contradictory  attributes  can  not  be  inherited  from  both  parents. 

3.  The  child  may  inherit  the  attributes  of  either  parent  solely. 

4.  It  may  inherit  the  qualities  of  one  parent  in  some  respects  and 
of  the  other  in  other  respects. 

44  1  "Sanity  and  Insanity. " 


690  MENTAL   DISEASES. 

5.  It  may  inherit  the  father's  attributes  for  one  period  of  existence 
and  the  mother's  for  another. 

6.  Some  attributes  have  the  quality  of  prepotency,  or  the  tendency 
to  push  aside  or  overrule  other  attributes. 

7.  Attributes  which  are  similar  in  both  parents  tend  to  become  pre- 
potent, giving  rise  to  convergent  or  cumulative  heredity. 

8.  Attributes  may  be  transmitted  in  latent  form  from  one  genera- 
tion to  another,  to  reappear  in  a  third  or  fourth  or  still  more  remote 
generation — a  phenomenon  termed  "  reversion." 

9.  Attributes  tend  to  appear  in  the  progeny  about  the  same  time  of 
life  at  which  they  became  manifest  in  the  parents. 

10.  Attributes  of  the  father  tend  to  be  inherited  by  the  sons  and  of 
the  mother  by  the  daughters. 

A  study  of  the  above  laws  will  explain  many  of  the  puzzling 
features  of  psychopathic  heredity, — why,  for  instance  often  only  a  few  of 
the  children  of  a  neurotic  parent  suffer  from  neuroses  or  psychoses,  and 
why  psych oneu roses  may  develop  in  the  progeny  of  healthy  parents 
(latency).  It  must  be  remembered,  too,  that  there  is  a  variation  in  the 
degree  of  hereditary  taint  originated  by  the  several  heritable  equiva- 
lents. Thus,  simple  neurasthenia,  eccentricity  of  character,  and  a  puer- 
peral or  senile  psychosis  are  not  so  serious  a  heritage  as  epilepsy, 
chronic  alcoholism,  paranoia,  and  imbecility.  The  taint  in  a  family  is 
greater  the  larger  the  number  of  members  and  branches  afflicted. 
When  the  degree  of  hereditary  taint  is  marked,  the  psychoses  which 
may  develop  tend  to  be  modified  from  the  ordinary  types  of  such  psy- 
choses, and  this  deviation  is  termed  hereditary  degenerative  modifica- 
tion,— or,  in  short,  hereditary  degeneracy, — while  the  insanity  evolved  is 
designated  as  a  degenerative  psychosis.  The  particular  degenerative 
psychoses  are  such  forms  as  idioc}^,  imbecility,  feeble-mindedness,  peri- 
odical and  circular  insanity,  hysterical  insanity,  acute  simple  paranoia, 
polymorphic  insanity,  etc.  A  polymorphic  course  is  particularly  char- 
acteristic of  psychic  degeneracy,  so  that  sometimes  a  perfect  chain  of 
psychopathic  conditions  and  psychoses  will  be  manifested  throughout 
the  life  of  the  degenerate. 

The  polymorphism  of  hereditary  transmission  sometimes  manifests 
itself  in  what  is  known  as  progressive  hereditary  degeneracy.  For 
example,  drunkenness  in  one  generation  may  lead  to  simple  psychoses 
in  the  next,  to  complex  degenerative  psychoses,  epilepsy,  etc.,  in  the 
third  generation,  and  finally,  in  the  fourth,  to  idiocy,  sterility,  and  the 
annihilation  of  the  stock. 

The  indications  of  degeneracy  in  an  individual  are  termed  the  stig- 
mata of  degeneration,  or  stigmata  hereditatis.  They  may  be  defined  as 
anatomical  or  functional  deviations  from  the  normal,  which  in  them- 
selves are  usually  of  little  importance  as  regards  the  existence  of  an 
organism,  but  are  characteristic  of  a  marked  or  latent  neuropathic  dis- 
position. Much  study  has  of  late  years  been  devoted  to  these  indices 
by  many  investigators,  particularly  in  their  relation  to  insanity,  idiocy, 
and  criminal  anthropology,  and  it  behooves  all  who  have  to  do  with  the 
development  and  care  of  the  human  body  in  any  particular — and  this 


GENERAL   ETIOLOGY  OF  INSANITY.  691 

refers  especially  to  men  of  the  medical  and  allied  professions — to 
familiarize  themselves  with  these  signs  of  degeneration,  in  so  far  as  they 
concern  their  own  special  provinces  of  work.  These  stigmata  are  vices 
of  functional  and  organic  evolution.  The  deviations  from  the  normal 
may  be  in  the  way  of  excesses  or  arrest  of  development.  They  must 
be  distinguished  from  the  deficiencies  or  deformities  produced  by  acci- 
dents at  birth  or  by  disease.  I  have  said  that  these  stigmata  are  ana- 
tomical and  functional,  but  it  is  more  convenient  to  divide  the  func- 
tional group  into  physiological  and  psychic  classes.  It  is  the  latter 
which  we  are  more  apt  to  observe  in  our  social  relations  with  degenerate 
individuals.  The  psychic  stigmata  are  always  characterized  by  want 
of  balance  or  lack  of  proportion  between  certain  undeveloped  or  exces- 
sively developed  faculties  and  other  faculties  which  are  normal.  De- 
fect of  moral  sense,  of  attention,  of  memory,  will,  judgment,  or  unbal- 
anced excess  of  musical  or  mathematical  aptitudes  may  be  cited  as 
instances  of  psychic  stigmata.  Hence  the  three  following  divisions 
may  be  made  of  all  the  degenerative  indices  :  (1)  Anatomical  stigmata  ; 
(2)  physiological  stigmata ;  (3)  psychic  stigmata. 

Anatomical  Stigmata. 
Cranial  anomalies. 
Facial  asymmetry. 
Deformities  of  the  palate. 
Dental  anomalies. 
Anomalies  of  the  tongue  and  lips. 
Anomalies  of  the  nose. 
Anomalies  of  the  eye  : 

Flecks  on  the  iris  ;  strabismus  ;  chromatic  asymmetry  of  the  iris  ; 
narrow  palpebral  fissures. 

Albinism. 

Congenital  cataracts. 

Microphthalmos. 

Pigmentary  retinitis. 

Muscular  insufficiency. 
Anomalies  of  the  ear. 
Anomalies  of  the  limbs  : 

Polydactyly. 

Syndactyly. 

Ectrodactyly. 

Symelus. 

Ectromelus. 

Phocomelus. 

Excessive  length  of  the  arms. 
Anomalies  of  the  body  in  general : 

Herniae. 

Malformation  of  the  breasts,  thorax. 

Dwarfishness. 

Giantism. 

Infantilism.  / 

Feminism. 

Masculinism. 

Spina  bifida. 
Anomalies  of  the  genital  organs. 
Anomalies  of  the  skin. 

Polysarcia. 

Hypertrichosis. 

Absence  of  hair. 

Premature  grayness. 


692  MENTAL   DISEASES. 

Physiological  Stigmata. 

Anomalies  of  motor  function  : 

Retardation  of  learning  to  walk. 

Tics. 

Tremors. 

Epilepsy. 

Nystagmus. 
Anomalies  of  sensory  function  : 

Deaf-mutism. 

Neuralgia. 

Migraine. 

Hyperesthesia. 

Anesthesia. 

Blindness. 

Myopia. 

Hypermetropia. 

Astigmatism. 

Daltonism. 

Hemeralopia. 

Concentric  limitation  of  the  visual  field. 
Anomalies  of  speech  : 

Mutism. 

Defective  speech. 

Stammering. 

Stuttering. 
Anomalies  of  genito  urinary  function  : 

Sexual  irritability. 

Impotence. 

Sterility. 

Urinary  incontinence. 
Anomalies  of  instinct  or  appetite  : 

Uncontrollable  appetite  (food,  liquor,  drugs). 

Merycism. 
Diminished  resistance  against  exteroal  influences  and  diseases. 
Retardation  of  puberty. 

Psychic  Stigmata. 
Insanity. 

Idiocy. 

Imbecility. 

Feeble-mindedness. 

Pavor  nocturnus. 

Precocity  ;  one-sided  talents  ;  disequilibration. 

Eccentricity. 

Moral  delinquency. 

Sexual  perversion. 

Having  made  this  attempt  to  classify  the  various  stigmata,  we  may 
now  proceed  to  examine  them  in  some  detail : 

Cranial  Anomalies. — The  most  important  features  to  be  noted  in 
connection  with  the  head  are  asymmetry  and  a  variety  of  deformities. 
It  is  necessary  to  an  understanding  of  these  stigmata  to  go  over  briefly 
a  few  facts  of  craniometry  and  cephalometry. 

A  score  or  more  of  distinguished  anthropologists  of  the  present  cen- 
tury have  been  trying  to  discover  racial  distinction  in  human  skulls  ; 
but  the  fact  is  that  there  are  not  so  many  characteristics  of  race  in  the 
cranium  as  in  other  parts  of  the  body,  and,  accordingly,  there  are  still 
wide  differences  of  opinion  as  regards  a  scientific  craniological  classifi- 
cation.    Races  have  been  mingling  so  many  thousands  of  years   that 


GENERAL  ETIOLOGY  OF  INSANITY. 


693 


cranial  dissimilarities  are  the  rule  among  them,  even  in  tribes,  and  to 
some  extent  in  families.  These  diversities  of  form  have  been  designated 
as  dolichocephalic,  mesocephalic,  and  brachycephalic — words  which 
merely  convey  an  idea  of  the  relation  of  the  length  to  the  breadth  of 
the  skull  when  viewed  from  above.  The  anteroposterior  is  to  the 
biparietal  diameter  as  100  is  to  x,  is  the  formula  for  determining  this 
"  cephalic  index."  All  length-breadth  indices  below  78  are  considered 
dolichocephalic  ;  from  78  to  80,  mesocephalic ;  and  above  80,  brachy- 
cephalic. We  may  assume  that  the  physiological  limits  of  this  index 
are  70  to  90.     This  is  based  upon  thousands  of  measurements  of  skulls 


Fig.  269. 


by  various  investigators.  Any  excess  or  diminution  of  these  figures 
must  hence  be  regarded  as  pathological  (Fig.  269). 

But  while  one  skull  may  be  narrower  or  broader  than  another,  there 
is  compensation  in  other  diameters.  The  dolichocephalic  has  a  greater 
vertical  diameter,  for  instance,  than  the  brachycephalic  skull. 

Besides  these  characteristics,  something  must  be  said  regarding  the 
physiological  asymmetry  of  the  skull.  The  fact  that  the  arms  and  hands 
are  not  symmetrical  on  the  two  sides  of  the  body,  either  in  size  or  func- 
tion ;  that  the  legs  and  feet  are  not  symmetrical ;  that  the  left  cerebral 
hemisphere  is  larger  and  more  complicated  than  the  right,  would  natu- 
rally lead  us  to  anticipate  some  slight  asymmetry  of  the  two  sides  of  the 
skull,  and  the  facts  of  observation  support  us  in  the  statement  that  asym- 
metry is  the  rule  and  perfect  symmetry  the  exception.  More  than  a 
thousand  postmortem  examinations,  the  examination  of  several  hundred 
heads,  and  an  inspection  of  some  collections  of  skulls,  such  as  that  of 
Blumenbach,  where  I  have  particularly  noted  this  point,  together  with 
the  testimony  of  others,  justify  me  in  this  assumption. 

Asymmetry  sometimes  reaches  extraordinary  proportions, — often  with 
quite  a  normal  state  of  brain  function,  often  with  marked  psychopathic 
changes.  Outside  of  purely  physiological  asymmetry,  we  have  that 
depending  upon  defective  development  and  disease.  One  of  the  first  of 
nature's  constructive  principles  in  fashioning  the  skull  is  the  struggle 
of  its  contents  for  volume.  Hence,  as  long  ago  pointed  out  by  Vir- 
chow,  premature  synostosis  of  any  cranial  suture  will  lead  to  compen- 


694  MENTAL  DISEASES. 

satory  deformity.     So,  too,  will  arrest  of  developmen   in  any  center  of 


Fig.  270. — Chemocephalu.s. 

ossification,  or  a  unilateral  aplasia  or  hyperplasia  of  the  skull  bones,  or 
of  the  contents  of  the  skull. 

Aside  from  the  deformities  of  the  head  which  are  congenital  in  char- 
acter, the  diseases  which  most  commonly  produce  cephalic  deformation 
in  early  life  are  rachitis  and  hydrocephalus;  in  later  life,  tumors,  exo.s- 
toses,  etc.;  while  at  all  periods  of  life  the  shape  of  the  skull  is  menaced 
by  injuries,  from  a  forceps  delivery  to  a  falling  brick.  The  following 
are  some  of  the  commoner  designations  of  well-known  cranial  deformi- 
ties : 

Chemocephalus  is  flat-headedness.     In  this  there  is  flatness  at  the 


Fig.  271. — Leptocephalus. 


top  of  the  head.  The  condition  is  also  called  platicephalus  (Fis^. 
270). 

Leptocephalus. — Early  synostosis  of  the  frontal  and  sphenoid  pro- 
duces leptocephalus,  or  narrow-headedness  (Fig.  271). 

MacrocephalTis  is  a  large  head,  usually  due  to  hydrocephalus. 

Microcephalus  is  a  small  head,  due  either  to  aplasia  of  the  brain  or 
premature  syna'^tosis  of  the  sutures  (rarely  the  latter). 

Oxycephalus,  or  steeple-shaped  skull,  is  due  to  .synostosis  of  the 
parietal  with  the  occipital  and  temporal  bones,  with  compensatory  de- 
velopment in  the  region  of  the  bregma.  Another  name  for  this  \&acro- 
cephalus  (Fig.  272). 

Plagiocephalus,  or  oblique  deformity  of  the  head,  is  due  to  uni- 
lateral synostosis  of  the  frontal  with  one  of  the  parietal  bones  (Fig. 
273). 


GENERAL  ETIOLOGY  OF  INSANITY. 


695 


Scaphocephalus  is  probably  caused  either  by  too  early  union  of 
the  sagittal  suture  or  by  the  development  of  both  parietal  bones  from 
cue  center.     The  top  of  the  head  is  keel-shaped  (Fig.  274). 


Fig.  272. — Oxycephalus. 


Fig.  273. — Plagiocephalus. 


Trigonocephalus. — Premature  union  of  the  frontal  suture,  resulting 
in  very  narrow  forehead  and  great  width  behind,  giving  rise  to  the  terra 
trigonocephalus  (Fig.  275). 

The  two  systems  of  measurement — the  craniometrical  and  the  ceph- 
alometrical — differ  but  slightly  from  each  other,  the  former,  of  course, 
being  the  more  exact,  since  every  portion  of  the  naked  skull  is  attain- 
able. 

I  would   recommend  the  following  series  of  measurements  to  be 


Fig.  274. — Scaphocephalus. 


Fig.  275. — Trigonocephalus. 


taken — eleven  in  numl^er — in  order  to  form  a  just  idea  of  the  capacity, 
shape,  and  symmetry  of  any  head  (Figs.  276  and  277) :  (1)  The  circum- 
ference ;  (2)  the  jiaso-occipital  arc  (iNTto  7^  ;  (3)  the  nasobregraatic  arc 
(N  to  j3)  ;  (4)  the  bregmatolambdoid  arc  (/5  to  A)  ;  (5)  the  binauricular 
arc  ;  (6)  the  anteroposterior  diameter  [S  to  0) ;  (7)  the  greatest  trans- 
verse diameter  (length-breadth  index) ;  (8)  the  binauricular  diameter  ; 
(9)  the  two  auriculobregmatic  radii;  (10)  the  facial  length;  (11)  the 
empirical  greatest  height  (B  to  ^). 

In   addition    to    acquiring    these    mathematical   data,  cephaloscopic 


696 


MENTAL    DISEASES. 


drawings  are  invaluable  as  exhibitiuff  deformitv  clearlv  to  the  eve. 
Hence,  the  horizontal  circumference,  naso-occipital  curve,  and  binau- 
ricular  curve  should  be  taken  with  a  strip  of  lead,  or,  what  is  better, 
with  the  instrument  devised  l)y  Luys  (on  the  principle  of  the  hatter's 
conformateursj,  and  the  curves  projected  on  paper. 

Dolichocephalic  heads,  as  a  rule,  have  narrow,  and  brachycephalic 
have  broad,  faces.  Something  should  here  be  said  concerning  prog- 
nathism, of  which  there  are  several  forms.  The  best  method  of  deter- 
mining it  is  to  measure  the  angle  made  by  a  line  drawn  from  the  nasal 
root  to  the  junction  of  the  inferior  nasal  spine  and  alveolar  process 
(Fig.  277,  iV^to  x)  with  a  vertical  line  dropped  from  the  nasal  root  to 
Broca's  horizontal.  It  is  found  that  every  normal  skull  exhibits  this 
subnasal  prognathism,  but  there  is  a  wide  variation  in  degree.  Extra- 
ordinary prognathism,  orthognathism,  and  opisthognathism — meaning 
extreme  projection,  straightness,  or  inclination  backward  of  the  sub- 
nasal  line — are  pathological. 

The  empirical  greatest  height  of  the  head  is  an  approximate  measure- 


UVfY j.'L lU.  , 

\\     BlNAUR/C(/lAR-DJ/lM     f^/ 

Fig.  276. 


Fig.  277. 


ment  of  the  distance  between  the  basion  and  vertex  of  the  skull  [B 
to  /?,  or  U).  A  line  from  the  external  occipital  protuberance  to  the 
lowest  median  point  of  the  superior  maxilla,  just  above  the  incisors  (T 
to  M),  passes  almost  directly  through  the  basion.  Hence,  in  cephal- 
ometry,  by  taking  this  diameter  and  the  radii  from  each  extremity  to 
the  bi'egma,  we  have  a  triangle  (J/,  /J,  T)  whose  height  (i>,  /5)  is  easily 
ascertained.  The  height  averages  13.3  cm.  in  men,  12.3  in  women, 
and  the  physiological  variation  is  from  11.5  to  15. 

The  only  instruments  necessary  for  obtaining  the  data  just  described 
are  a  pair  of  calipers,  the  tape-line,  and  a  strip  of  sheet-lead  two  feet 
long  by  J  or  f  of  an  inch  wide.  Benedikt's  calipers  (manufactured 
by  Wolters  in  Vienna),  which  are  here  illustrated,  are  to  be  recom- 
mended for  their  exactness  (Fig.  278),  as  are  also  those  that  I  have  had 
made  for  my  own  use  (Fig.  279). 

Excessive  prognathism  is  found  among  criminals,  in  microcephaH, 
and  in  cases  of  hemi-  and  paraplegia  spastica  infantilis.  Skulls  known 
as  crania  progengea  have  consideral^le  pathological  significance.  In 
these,  lower  teeth  project  beyond  the  upper,  and  the  inferior  maxillary 


GENERAL   ETIOLOGY  OF  INSANITY. 


697 


angle  is  obtuse,  duo,  probiibly,  to  aplasia  of  the  upjxT  or  hyperplasia 
of  the  lower  maxilla. 

The  clenioustration  of  the  enipirieal  greatest  height  is  ofteu  quite 
valuable  as  an  index  of  degenerative  and  neuropathic  types.  The 
following  are  some  general  points  which  should  be  considered  in  the 
examination  of  these  cases  : 

A  skull  below  the  normal  tyj)e  in  volume  belongs  to  an  abnormal 
individual. 

Undertypical  measurements  of  the  head  should  always  lead  us  to 
entertain  the  suspicion  of  defective  cerebration. 

Abnormal  smallness  of  any  part  of  the  skull  permits  the  conclusion 
that  the  part  of  the  brain  in  its  neighborhood  is  imperfectly  developed. 

Excessive  development  of  the  head  has  a  double  signification.     It  is 


AilihhhlAilAAAAi 


riTiTiTiTiTiTrriTiT^) 


Fig.  278.— Benedikl's 
calipers. 


Fig.  279. — Author's  calipers. 


always  pathological,  but  may  mean  abnormality  of  brain  or  successful 
compensation.  Wormian  bones  are  also  doubly  significant.  They 
either  represent  a  pathological  process  or  a  successful  effort  of  nature 
in  repair. 

Hemiplegia  spastica  infantilis,  epilepsy,  and  intellectual  or  ethic 
weakness  often  exhibit  unilateral  aplasia  of  the  skull. 

The  skull  is  representative  of  the  brain  only  during  the  years  of  its 
development,  and  it  must  be  remembered  that  psychopathic  deteriora- 
tion often  has  its  inception  subsequent  to  the  completion  of  the  process, 
when  no  impression  can  be  made  upon  its  bony  walls. 

I  have  prepared  a  table  of  the  measurements  recommended,  showing 
the  averages  in  adults,  male  and  female,  together  with  the  physiological 
variation,  excesses  above  or  below  which  are  significant  of  morbidity. 
It  is  based  upon  the  examination  of  some  hundreds  of  skulls  and 
heads,  and  upon- statistics  given  by  various  authorities  who  have  made 
especial  study  of  this  department  of  anthropometry.  Hence  it  may 
be  depended  upon  as  a  fair  estimate  of  the  dimensions  of  the  head  in 
most  of  the  Caucasian  races.     The  table  is  as  follows  : 


698 


MENTAL   DISEASES. 


Table  of  Craniometeical  Measurements. 


avekage in 

Adult  in 

Centimeters. 

Ph      > 

1 

.2 

"3 

Remarks. 

1.  Circumference, 

52 

50 

48.5-57.4 

Roughly  approximated,  the 
volume  is  to  the  circum- 

2. Volume, 

1500 

1300 

1201-1751 

ference  as  1350  c.c.  is  to 
50  cm. 

3.  Naso-occipital  arc,    .... 

32 

31 

28-38 

In  figure,  N  to  T. 

4.  Nasobregmatic  arc,          .    . 

12.5 

12 

10.9-14.9 

iVto/3. 

5.  Bregraatolambdoid  arc, 

12.5 

11.9 

9.1-14.4 

^ioA. 

6.   Biuauricular  arc,      .        .    . 

32 

31 

28.4-35 

7.   Anteroposterior  diameter, 

17.7 

17.2 

16.5-19 

S  to  0. 

8.  Greatest  transverse  diameter 

14.6 

14 

13-16.5 

The  formula  for  the  length- 
breadth  index  is  : 

Length  :  Breadth  : :  100  :  x. 

An  index  below  78  is  doli- 
chocephalic ;  78  to  80, 
mesocephalic  :  above  80, 
brachycephalic. 

9.  Length-breadth  index,     .    . 

82.2 

83.8 

76.1-87 

10.  Binauricular  diameter,    . 

12.4 

11.9 

10.9-13.9 

B           The   height 

A           B-X  of  the 

/  i  \         triangle    E, 

/    \    \      -S,  ^formed 

p/        ■        Xi^bv  the  anri- 

11.  Auriculobregmatic  radii,    . 

^            culobregma- 
tic  radii  and  the  binauri- 
cular  diameter,  averages 
11.17    v^ath     a    variation 
from  10  to  12.65. 

12.  Facial  length, 

12.37 

— 

10.5-14.4 

From  root   of  nose,  N,  to 
lowest  part  of  chin. 

13.  Empirical  greatest  height, 

13.3 

12.3 

11.5-15 

The      empirical     greatest 
height,  B,  /3,  is  obtained 
by  measuring  the  sides  of 
the  triangle  if,  3,  T. 

These  measurements  are  those  of  the  adult  human  skull.  As  the  hair  and  scalp 
superadd  about  3  cm.,  about  6  per  cent,  should  be  deducted  in  the  head  measurements 
Nos.  1,  3,  and  6  to  obtain  those  of  the  skull.  In  taking  the  diameters  Nos.  7  and  8, 
deduct  1  cm.  (the  scalp  averaging  5  mm.  in  thickness),  and  from  the  shorter  radii,  such 
as  Nos.  10  and  11,  subtract  but  7  mm. 


Facial  Asymmetry. — Inequality  of  the  two  sides  of  the  fece — 
when  congenital  and  not  due  to  some  such  disease  as  hemiatrophy — is 
to  be  looked  upon  as  a  stigma  of  degeneration.  In  the  same  category 
may  be  grouped  various  irregularities,  and  such  conditions  as  excessive 
prognathism  or  retrognathism.      Great  prominence  or  unequal  promi- 


GENERAL  ETIOLOGY  OF  INSANITY. 


699 


nence  of  the  malar  bones  is  to  be  observed,  and  also  asynnnetry  of  the 
orlMts  (Fig.  280). 

Deformities  of  the  Palate. — In  connection  with  the  soft  palate, 
bifnrcation  of  the  uvula  may  be  mentioned.  As  regards  the  hard 
palate,  I  have  dwelt  upon  its  deformities  at  some  length  in  an  article  in 
the  '^  International  Dental  Journal"  (December,  1895),  and  the  facts 
there  brought  forward  may  be  recapitulated  as  follows  : 

While  the  palate  occupies  but  a  small  place  in  this  great  category  of 
hereditary  stigmata  of  all  kinds,  it  is  one  of  the  anatomical  group,  and 
this  group  is  for  many  reasons  the  one  of  greatest  importance.     In  this 


Fig.  280. — Male  epileptic,  aged  forty  years,  with  glabrous  face  and  chin  aud  facial  asymmetry. 


group,  too,   it  occupies  a  distinctive  place  as  being   among  the   most 
striking,  frequent,  and  significant  of  the  anomalies. 

The  arch  of  the  hard  palate  presents  considerable  variation  within 
strictly  normal  anatomical  limits.  A  large,  wide,  moderately  high 
vault  is  what  may  be  called  a  normal  standard.  It  means  the  highest 
evolution,  judging  from  the  fact  that  the  mouth-cavity  increases  in 
capacity  as  we  ascend  the  vertebrate  series.  Deviations  from  that 
standard  are  not  at  all  infrequent,  and  yet  such  deviations  may  be  nor- 
mal. Thus,  the  palate  may  be  low  and  broad,  or  it  may  be  high  and 
narrow  ;  it  may  be  short  or  long  in  its  anteroposterior  diameter  ;  it 
may  be  ridged  unduly  along  the  palatine  sutures,  or  it  may  present 
marked  rugosities  on  its  surface,  especially  in  the  anterior  region ;  yet 
these  variations  are  normal.      Probably  we  may  look  upon  these  pecu- 


700  JTEXTAL   DISEASES. 

liaritles  as  a  species  of  compensatory  development.  Just  as  in  a  -tudy 
of  heads  we  find  some  very  long  and  low^  and  others  short  and  round 
and  high,  and  recognize  the  fact  that  the  shortness  in  one  dimension  is 
compensated  for  by  a  corresponding  increase  in  another,  so  we  may 
regard  variation  in  palatine  diameters. 

The  pathological  palate  lias  not  been  studied  as  much  as  it  deserves 
to  be.  Save  occasional  and  casual  references  to  the  ••'  Gothic  "  palate 
in  literature,  and  one  or  two  papers  upon  the  '-'torus  palatinus,"  veiy 
little  has  been  written  upon  the  sulDJect.  In  my  paper,  previously  referred 
to,  I  have  attempted  to  classify  such  pathological  palates  as  could  be  justly 
looked  upon  as  indicative  of  degeneracy.  The  word  Gothic  having  been 
so  long  in  use,  and  the  hard  palate  being  much  like  an  arch  or  roof.^  I 
have  followed  architectural  nomenclature  in  the  classification  offered. 

Pathological  Palates  : 

1.  Palate  with  Gothic  arch  (Fie.  281). 

2.  Palate  with  horseshoe  arch  (Fis.  282). 

3.  The  dome-shaped  palate  (Fisr.  283). 

4.  The  flat-roofed  palate  (Fig.  284). 

5.  The  hip-roofed  palate  (Fie.  285). 

6.  The  asymmetrical  palate  (Fie.  286). 

7.  The  torus  palatinus  (Fig.  287). 

The  seven  varieties  named  are  to  be  looked  upon  as  types  merely. 
Each  tvpe  will  be  found  to  present  variations  and  combinations  with 
other  forms.  Thus,  the  Gothic  arch  may  have  a  low  or  high  pitch  and 
be  short  or  long.  The  horseshoe  arch  (a  familiar  one  in  Moorish  archi- 
tecture) is  always  easily  distinguished,  but,  owing  to  its  conformation, 
a  cast  can  not  well  be  taken  of  it  to  show  it  in  a  perfect  outline.  The 
dome-shaped  j^alate  may  be  high  or  lo\v,  may  be  combined  with  asym- 
metrv  or  torus.  The  presence  of  a  torus  in  the  Gothic  variety  is  apt  to 
destrov  the  purely  Gothic  form,  and  may  cause  it  to  resemble  the  flat- 
roofed  palate.  Under  the  heading  of  flat-roofed  palate!  shr)uld  include 
all  such  palates  as  are  nearly  horizontal  in  outline,  as  well  as  those  with 
inclined-roof  sides  but  flattened  gable.  In  the  hip-roofed  palate  we 
have  the  sloping  sides  as  usual,  but  also  a  marked  pitch  of  the  palate 
roof  in  front  and  behind  ;  occasionally  one  may  meet  with  a  palate  of 
this  kind  with  so  remarkable  a  pitch  from  before  backward  that  it  is 
almost  like  a  Gothic  roof  turned  about  .so  that  the  gable  runs  trans- 
versely. 

Asymmetry  in  the  palate  is  commonly  ob.sen'ed  in  many  of  the 
previouslv  described  forms,  but  occasionally  is  the  only  noteworthy 
peculiarit}^.  It  is  usual  to  find  asymmetry  of  the  face  and  skull  in 
cases  with  an  asymmetrical  palate.  The  torus  palatinus  (Latin  torus, 
swelling)  was  first  mentioned  by  Chassaignac  as  a  mediopalatine  exos- 
tosis. It  is  a  projecting  ridge  or  swelling  along  the  palatine  suture, 
sometimes  in  its  whole  length,  sometimes  in  only  a  portion  of  its  course. 
It  is  always  congenital.      It  varies  consideral  Jy  in  its  shape  and  size,  so 

^  "  There  is  some  confusion  in  literature  of  the  roof  of  the  mouth,  or  hard  palate, 
referred  to  in  this  paper,  with  the  dental  arch,  which  is  quite  another  thing." 


GENERAL  ETIOLOGY  OF  INSANITY. 


•01 


that  as  many  a.s  tive  oy  six  different  species  of  t(jrus  are  recounized.  It 
may  be  wedge-shaped,  narr(jw,  bnjad,  very  pnjminent,  or  irregular.  I 
have  said   nothing  about  cleft-palate,  for  I  am  not  sure  that  it  may  be 


Fig.  281.— Palate  with  Gothic  arch. 


Fig.  282.— Palate  with  horseshoe  arch. 


classed  among  the  well-marked  stigmata  of  degeneration.  I  have 
found  but  two  or  three  cleft-palates  among  the  450  idiots  and  imbeciles 
on  Randall's  Island,  while  a  number  of  cases  of  this  kind  with  which  I 


702 


MENTAL   DISEASES. 


have  come  in  contact  in  my  professional  life  were  very  far  from  degen- 
erates. However,  it  wonld  seem  that  there  is  great  need  of  a  faithful 
study  of  a  large  number  of  cases  of  cleft-palate  in  relation  to  the  ques- 


Fig.  283.— The  dome-shaped  palate. 


Fig.  284.— The  flat-roofed  palate. 


tion  of  degeneracy.     The  deformed  palate  is,  to  my  mind,  one  of  the 
chief  anatomical  stigmata  of  degeneration. 

It  is  true  that,  from  this  single   indication,  it  would   not  be  strictly 


GENERAL   ETIOLOGY  OF  INSANITY. 


703 


scientific  to  adjudge  an  individual  a  degenerate.  Occasionally,  perhaps, 
a  case  presents  itself  where  this  anatomical  stigma  alone  would  suffice 
to  insure  a  diagnosis  of  this  nature ;  but  usually  other  stigmata  coexist, 
such  as  cranial  anomalies,  deformities  of  the  ear,  and   the   like.     The 


Fig.  2S5.— The  hip-roofed  palate. 


Fig.  286. — The  asymmetrical  palate. 


frequency  of  the  pathological  palate  among  marked  degenerates,  such  as 
the  insane,  idiots,  and  epileptics,  has  been  testified  to  by  many  investi- 
gators. Thus,  Talbot  reported  43  per  cent,  of  abnormal  palates  in 
1605  inmates  in  institutions  for  the  feeble-minded.  Ireland  makes 
it  nearer  50  per  cent.     Charon,  a  later  writer  than  these,  found  abnor- 


704  3IENTAL   DISEASES. 

mal  palates  in  10  per  cent,  of  apparently  normal  persons,  in  82  per 
cent,  of  idiots  and  feeble-minded,  in  76  per  cent,  of  epileptics,  in  80  per 
cent,  of  cases  of  insanity  in  general,  in  70  per  cent,  of  the  hysterical 
insane,  and  in  35  per  cent,  of  cases  of  general  paralysis.  Nacke  has 
studied  particularly  the  torus  palatinus  in  14-19  individuals,  normal  and 
psychoj)athic ;  he  found  it  present  in  23.9  per  cent,  of  psychopathic 
women  (insane,  epileptic,  idiot,  and  criminal),  32.9  per  cent,  of  epilep- 
tic women,  34.4  per  cent,  of  criminal  women,  22.7  per  cent,  of  normal 
women.  The  percentages  were  smaller  in  men  than  in  women.  A 
narrow  torus  is  more  common  than  a  broad  one. 

Stieda  examined  1500  skulls  for  the  torus  from  an  anthropological 
point  of  view.  The  skulls  were  of  Prussians,  Armenians,  Africans, 
Frenchmen,  Russians,  and  Asiatics.  He  decided  that  it  has  no  anthro- 
pological significance  ;  gives  no  racial  distinction.     While  the  torus   is 


"~-  Fig.  287. — Torus  palatinus  (broad,  wide  torus). 

undoubtedly  of  value  as  an  index  of  degeneration,  particularly  where  it 
is  well  marked,  it  probably  has  less  importance  in  this  respect  than 
some  of  the  other  forms  of  pathological  palate. 

Dental  Anomalies. — Among  anomalies  of  the  teeth  are  macro- 
dontism,  microdontism,  projecting  teeth,  badly  placed  or  misplaced 
teeth,  double  row  of  teeth,  or  teeth  which  are  striated  transversely  or 
longitudinally.  Caries  of  the  teeth  and  Hutchinson's  teeth  are  due  to 
neglect  or  disease.  The  latter,  however,  may  often  be  considered  as  a 
stigma  of  degeneration.  Then  there  is  a  retardation  of  the  first  and 
second  dentition. 

Anomalies  of  the  Tongue  and  Lips. — A  very  large  tongue 
(macroglossus)  is  not  infrequently  observed  among  the  lowest  classes  of 
degenerates,  as  in  idiocy.  Sometimes  there  is  microglossus,  asymmetry 
of  the  two  halves,  or  bifidity  of  the  point.  Harelip  is  somewhat  more 
common  than  cleft-palate,  but,  like  the  latter,  its  exact  standing  as  a 


GENERAL   ETIOLOGY  OF  INSANITY.  705 

degenerative  stigma  is  not  fully  detcnnined.  Undne  swelling  or 
pnffiness  of  the  Ii])s  is  noteworthy. 

Anomalies  of  the  Nose. — Marked  deviation  ol'  the  nose  to  one 
side  or  the  other  shonld  he  noted.  Talcen  alone  it  may  possess  little 
significance,  bnt  in  eonjnnction  with  other  stigmata  it  is  of  value.  The 
nose  may  be  absent,  or  present  defect  of  osseous  development  (nasus 
ad  Knells'^  or  atresia  of  the  nasal  fossfe. 

Anomalies  of  the  Eye. — The  pathological  conditions  of  the  eye 
have  been  ])laeed  in  two  groups  in  the  foregoing  classification,  since  some 
are  anatomical  and  some  physiological.  To  enumerate  them  altogether, 
they  are  as  follows  : 

Anatomical.  Physiological. 

Flecks  on  the  iris.  Blindness. 

Strabismus.  _  _  Myopia. 

Chromatic  asymmetry  of  the  iris.  Hypermetropia. 

Narrow  palpebral  fissures.  Astigmatism. 

Albinism.  Daltonism. 

Congenital  cataracts.  Hemeralopia. 

Pigmentary  retinitis.  Concentric  limitation  of  the  visual  field. 

Microphthalmos.  Nystagmus. 

Muscular  insufl&ciency. 

It  is  true  that  any  one  or  two  or  more  of  these  conditions  present  do 
not  certainly  indicate  degeneracy,  but  they  are  significant  in  connection 
with  other  abnormal  states,  and  all  of  them  are  more  frequently 
observed  in  degenerate  individuals,  especially  the  lower  orders,  than  in 
normal  persons.  In  idiots,  convergent  strabismus,  due  to  defect  of 
refraction  and  in  conjunction  with  hypermetropia,  is  very  common. 
Muscular  insufficiency  and  nystagmus  (lateral  or  rotatory)  are  also  often 
met  with  in  this  class  of  cases.  In  paralytic  and  other  idiots  and  imbe- 
ciles homonymous  hemianopsia  is  sometimes  met  with. 

Anomalies  of  the  Ear. — Deformities  of  the  ear  have  been  de- 
servedly well  studied,  for  as  stigmata  of  degeneration  they  take  high 
rank,  like  anomalies  of  the  hard  palate,  in  the  anatomical  group. 
Morel,  Stahl,  Wildermuth,  Binder,  and,  more  recently,  Schwalbe,  have 
given  us  especially  good  studies  of  these  conditions.  From  their 
writings  and  my  own  studies,  the  following  classification  (following 
Binder)  into  twenty-two  varieties  may  be  made  : 

I.  Abnormally  implanted  ears  ;  they  project  too  far  or  lie  too 
closely,  are  placed  too  high  or  too  low,  too  far  forward  or  too  far 
backward  on  the  head. 

II.  Excessively  large  ears  :  (1)  absolutely  too  large ;  (2)  rela- 
tively too  large  in^  small  or  microcephalic  individuals. 

III.      Ears  which  are  too  small. 
.    IV.     Too  marked  conchoidal  shape  of  the  ear.     The  details  of  the 
ear  (anthelix  and  crura,  etc.)  are  but  slightly  marked,  while  the  helix 
outlines  the  ear  like  the  rim  of  a  funnel. 

V.  Ears  which  have  a  general  ugly  shape.  The  breadth  of  the 
upper  part  may  exceed  that  of  the  lower,  and  vice  versa  ;  excessive 
length  ;  ears  without  lobules  ;  unusually  short  ears. 

4'^ 


706 


MENTAL   DISEASES. 


VI.     Ear  not  uniform  in  width ;  usually  a  long   ear  with   one 
or  more  constrictions  in  its  breadth. 

VII.  The  Blainville  ear ;  asymmetry  of  various  kinds  of  the 
two  ears.  In  most  cases  the  asynmietry  is  due  to  an  anomaly  of  the 
left  ear. 


Fossa  ovalis 


Fossa  cymbse 


Fossa  concha 


Incisura  intertragica 


Fig.  288.— Normal  ear. 


Fossa  scaphoidea 


VIII.  The  ear  without  lobule  ;  there  are  usually  other  deformities 
of  this  ear  besides  the  absence  of  lobule,  such  as  too  large  a  concha, 
prominence  of  the  anthelix,  etc, 

IX.     The  ear  with  adherent  lobule ;  the  lobule  is  enlarged,  ad- 
herent, and  inclines  downward  toward  the  cheek. 


Fig.  289. — Blainville  ear ;  also  excessive  length 
of  ears. 


Fig.  290.— Morel  ears. 


X.     The  Stahl  ear.  No.  l.i     A  series  of  anomalies  of  the  helix. 
The  helix  is  broad,  like    a   band,  and    coalesces  with    the    cartilages 


^  See  "  Zeitschrift  flir  Psych.,"  vol.  xvi. 


GENERAL   ETIOLOGY  OF  INSANITY. 


707 


of  the  crura  furcuta.  The  fossa  ovalis  and  fossa  scaphoidea  are 
scarcely  to  be  seen.  The  lower  half  of  the  helix  is  obliterated.  There 
are  occasionally  slight  variations  from  this  type. 

XI.  The  Darwin  ear  ;  helix  interrupted  where  its  transverse 
portion  passes  into  the  descending,  and  at  this  point  is  a  projection  of 
the  rim  above  and  outward,  like  the  pointed  ear  of  lower  animals. 

XII.  The  Wildermuth  ear.i  The  anthelix  projects  so  far  as 
to  form  the  most  prominent  part  of  the  auricle. 

XIII.  The  ear  without  anthelix  or  crura  furcata. 

XIV.  The  Stahl  ear,  Xo.  2.  Multiplication  of  the  divisions  of 
the  crura  furcata,  so  that  there  are  three  instead  of  two  crura. 

XV.  AVildermuth's  Aztec  ear.  Lobule  wanting ;  the  whole 
ear  seems  pushed  forward  and  downward  ;  the  crus  superius  of  the 
anthelix  coalesces  with  the  helix,  wdiile  its  crus  anterius  is  scarcely 
perceptible. 

XVI.  The  Stahl  ear,  Xo.  3.  Only  the  crus  anterius  of  the  crura 
furcata  is  present,  while  the  auricle  seems  divided  into  two  halves  by  a 
ridge  from  the  antitragus. 

XVII.     The  ear  with  double  helix. 


Fig.  291.— Stahl  ear,  No.  1. 


Fig.  292. — Darwin  ear. 


XVIII.     The  ear  with  too  large  or  too  small  a  concha. 

XIX.  The  ear  with  continuous  fossa  scaphoidea.  The  fossa 
passes  down  into  the  lobe. 

XX.  The  Morel  ear.  A  form  marked  by  abnormal  develop- 
ment of  the  helix,  anthelix,  fossa  scaphoidea,  and  crura  furcata,  so  that 
the  folds  of  tiie  ear  seem  obliterated,  and  the  ear  is  smooth,  larger  than 
usual,  often  prominent,  and  with  thin  edge. 

XXI.  Ears  misshapen  by  abnormal  cartilage  development. 
Here  belong  all  Irregular  cartilaginous  growths  and  thickenings  except 
those  caused  by  hematoma  of  the  ear. 

XXII.  Various  peculiarities,  difficult  to  classify,  are  included 
here,  such  as  abnormalities  of  the  semilunar  incisure  of  the  tragus  and  of 
the  meatus,  coloboma  of  the  lobule,  hairiness  of  the  different  parts  of 
the  auricle,  accessory  ears,  clefts,  etc. 


1  "  Wurt.  Corresp.-Blatt,"  1886,  No.  40. 


708 


MENTAL   DISEASES. 


The  most  important  malformations  of  the  ear — those  that  may  be 
regarded  as  belonging  to  the  stigmata  of  degeneration,  and  those,  too, 
which  are  striking  and  plain  to  the  eye — are  to  be  summarized  as 
follows  : 

The  deep  position  of  the  crus  anterius. 

Marked  prominence  of  the  anthelix. 

Excessive  broadening  of  the  ear. 

Stunted  development  of  or  absence  of  the  helix. 

Trlfurcation  of  the  anthelix. 

Widening  of  the  fossa  scaphoidea. 

Absence  of  the  crus  superius. 

Complete  absence  of  lobule. 

Asymmetry  of  the  two  ears. 

Excessive  enlargement  or  diminution  of  the  concha. 

Excessive  conchoidal  structure  of  the  ear. 

Reference  is  occasionally  made  in  literature  to  the  Cagot  ear.  The 
Cagot  is  a  species  of  cretin  in  the  French  and  Spanish  Pyrenees,  in 
which  one  of  the  chief  physical  deformities  is  absence  of  the  lobule  of 
the  ear. 

Binder  states  that  the  adherent  lobule  exists  in  almost  one-third  of 
normal  persons,  and  in  the  photographs  of  several  hundred  distinguished 
persons  15  per  cent,  had  abnormal  lobules.     At  the  same  time  more 


Fig.  293. — Excessive  length  of  ears;  facial  a-symmetrv. 


than  twice  as  many  adherent  lobules  are  found  in  degenerates  as  in 
normal  individuals. 

Now,  with  regard  to  statistics  of  malformed  ears  in  degenerate  in- 
dividuals, Wildermuth  noted  this  condition  in  41  per  cent,  of  142  idiots. 
Binder  found  64  per  cent,  of  degenerate  ears  in  354  in.sane  persons. 
It  is  to  be  remarked,  however,  that  Binder  was  more  careful  in  his  ex- 
aminations, and  by  long  practice  had  acquired  more  expert  knowledge 
than  Wildermuth.  Frankel  observed  degenerate  ears  in  29  cases  out 
of  32  with  cranium  proganseum. 

Knecht  found  20  per  cent,  of  degenerate  ears  among  1274  criminals, 
27  per  cent,  among  48  epileptics,  and  32  per  cent,  among  84  insane. 


GENERAL   ETIOLOGY  OF  INSANITY. 


709 


Binder  noted  degenerate  ears  in  33  persons  outside  of  institutions, 
supposed  to  be  normal  individuals.  Inquiring  closely  into  their  his- 
tories, he  discovered  that  7  of  them  had  insane  parents,  brethren,  or 
children;  in  19  there  were  decided  psychic  abnormalities,  and   only  7 


Fig.  294. — Broad,  band-like  helix  ;  no  ant- 
helix  ;  no  lobule ;  excessive  size  of  fossa  cyni- 


Fig.  295. — Excessive  length  of  ear  ;  fusion 
and  distortion  of  helix,  anthelix,  antitragus,  and 
lobule. 


Fig.  296. — Triplication  of  crura  furcata;  mal 
formed  helix  and  antitragus ;  absent  lobule. 


Fig.  297. — Fissure  in   anthelix;   slight  Darwin 
tubercle ;  slight  antitragus. 


Fig.  298. — No  crus  superius  ; 
no  anthelix ;  small  fossa  con- 
chae  ;  few  details  of  ear. 


Fig.  299.  — No  lobule;  no 
fossa  conchse ;  shallow  fossa 
scaphoidea ;  fusion  of  helix, 
anthelix,  and  antitragus  ;  a  type 
of  Stahl  ear.  No.  3. 


Fig.  300. — Prominent  anthe- 
lix; maldevelopeii  helix;  ab- 
sence of  lobule;  diminution  of 
the  concha ;  Wildermuth  ear, 
No.  1. 


were  apparently  normal  persons.  As  regards  heredity,  it  is  very  com- 
mon for  children  to  inherit  ears  with  the  identical  characteristics  of 
those  of  one  or  the  other  parent,  but,  on  the  other  hand,  it  is  not  uncom- 
mon for  the  ears  of  the  children  to  be  quite  different. 


710 


MENTAL  DISEASES. 


Anomalies  of  the  Limbs. — Paralysis,  atrophy,  retarded  g^o^^i:h, 
club-foot,  and  athetosis  are  conditions  due  to  disease  of  the  brain,  and 
are  observed  in  many  cases  of  paralytic  idiocy.  These  are  not  properly 
stigmata  of  degeneration,  although  they  may  be  such  under  some  cir- 
cumstances, as,  for  instance,  when  club-foot  or  club-hand  has  a  terato- 
logical  origin.  On  the  other  hand,  there  are  anomalies  having  a 
hereditary  character,  which  are  essentially  degenerative  indices.  Among 
these  may  be  mentioned  congenital  luxations,  supernumerary  fingers  or 
toes  (Polydactyly),  fusion  of  fingers  or  toes  (syndactyly  or  aschistodactyly), 
excessive  length  of  the  arms  as  compared  with  the  rest  of  the  body  and 
the  lower  limbs,  missing  fingers  or  toes  (ectrodactyly),  missing  limb 
(ectromelusj,  fusion  of  the  extremities  (symelus  or  symmelus),  or  ab- 
sence of  parts  of  limbs  so  that  they 
are  excessively  short  (phocomelus). 
There  may  also  be  anomalous  brevity 
of  some  digits  as  compared  with  the 
relative  proportions  of  normal  digits. 
Excessive  volume  of  limbs  (megal- 
omelus)  or  digits  (megalodactyly)  or 
excessive  gracility  of  limbs  (oligo- 
melus)  or  of  digits  (oligodactyly)  also 
deserve  mention. 

Anomalies  of  the  Body  in 
General. — Local  malformations  are 
naturally  of  more  importance  than 
general  anomalies  of  the  whole  form, 
but  it  is  necessary'  to  study  the  rela- 
tive proportions  of  the  entire  figure 
from  an  anthropometrical  point  of 
view,  and  to  compare  the  results  with 
normal  standards.  Excessive  dim- 
inutiveness  of  figure,  as  well  as  ex- 
cessive or  giant  growth,  are  indications 
of  degeneracy.  So,  too,  are  infantile 
characteristics  in  an  adult,  feminine 
peculiarities  in  males,  and  masculine 
traits  in  females.  In  this  regard,  observations  of  the  relative  pro- 
portions of  the  shoulders  and  pelvis  are  particularly  useful.  The 
occult  form  of  spina  l^ifida  with  local  hypertrichosis  is  met  with. 
Deviation  of  the  vertebral  column  among  neuropaths  is  mentioned  by 
Fere.  They  may  be  lordoses,  scolioses,  or  kyphoses  in  various  degrees. 
The  coccyx  may  present  peculiarities,  such  as  simulation  of  a  tail. 
Thoracic  asymmetry  or  other  deformity  is  observed  at  times.  Absence 
of  pectoral  muscles,  or  of  muscles  in  various  parts  of  the  body,  has 
significance.  Hernise  are  evidence  sometimes  of  arrest  of  development 
of  some  part  of  the  abdominal  wall.  Excessive  development  of  mam- 
mary glands  in  males,  or  their  absence  or  reduplication  (polymastia)  in 
either  sex,  constitutes  an  evidence  of  degeneracv. 

Anomalies  of  the  Genital  Organs. — Among  the  genital  anomalies 


Fig.  301. — Phocomelus  right  arm  in  epi- 
leptic girl;  right  humerus  several  inches 
shorter  than  left ;  arms  otherwise  perfect. 


GENERAL  ETIOLOGY  OF  INSANITY. 


in 


in  males  are  eryptorehisniiis ;  unilateral  or  bilateral  microrchidia ; 
spurious  hermaphroditism  ;  insufficient  development  of  the  entire  genital 
apparatus  ;  hypospadias  ;  epispadias  ;  defect,  torsion,  or  great  volume  of 
the  prepuce  ;  median  fissure  of  the  scrotum  ;  imperforate  meatus. 

In  females  the  labia  may  be  abnormally  large,  simulating  a  scrotum  ; 
sometimes  very  small.  The  clitoris  may  be  exceedingly  large.  The 
labia  minora  may  be  hypertrophied.  Sometimes  there  are  intermediate 
folds  between  the  labia  minora  and  labia  majora.  The  labia  minora 
may  be  pigmented,  particularly  in  brunets  and  when  they  are  hyper- 
trophic. There  may  be  imperforate  vulva,  or  atresia  of  the  vagina,  or 
double  vagina  ;  uterus  bicornis  is  sometimes  met  with. 

Anomalies  of  the  genito-urinary  apparatus  should  always  be  sought 
for,  for,  though  most  frequent  among  idiots,  imbeciles,  epileptics,  and 
the  like,  they  are  by  no  means  rare  in  other  classes  of  degenerates  and 
in  degenerate  families.  In  males,  defect  of  the  testicles  often  coincides 
with  general  excess  of  growth  in 
the  whole  body  or  in  the  lower 
extremities,  such  as  is  often  pro- 
duced by  castration  in  man  and 
lower  animals. 

Anomalies  of  the  Skin. — 
Among  the  anomalies  of  the  skin 
are  to  be  mentioned  adipose 
thickening ;  polysareia ;  preco- 
cious and  often  abnormal  devel- 
opment of  the  hairy  system  ;  hair 
along  the  spinal  column  ;  rudi- 
mentary tail ;  premature  gray- 
ness ;  a  glabrous  chin  in  grown 
men  ;  persistent  lanuginous  char- 
acter of  the  hair  ;  excessive  growth 
of  hair  on  the  chin  and  breast  in 
women  ;  complete  or  partial  dis- 
coloration of  the  hair  (albinism,  vitiligo)  ;  local  or  general  hypertri- 
chosis ;  partial  or  complete  absence  or  fetal  state  of  the  nails  ;  melanism 
of  the  skin  ;  pigmentary  or  vascular  nevi ;  molluscum  ;  ichthyosis  ; 
vitiligo  ;  albinism  ;  pigmented  spots. 

Anomalies  of  Motor  Function. — Delay  in  acquiring  a  knowledge 
of  the  proper  use  of  muscles  for  walking,  eating,  and  the  like  may 
often  be  regarded  as  an  index  of  degeneracy.  Where  ordinary  etio- 
logical factors  may  be  excluded,  tremors,  tics,  epilepsy,  and  nystagmus 
may  have  a  similar  value.  Even  when  not  congenital,  they  often  indi- 
cate hereditary  instability  of  the.  nervous  system. 

Anomalies  of  Sensory  Function. — The  numerous  anomalies  of 
function  in  connection  with  the  eye  have  already  been  mentioned. 
Congenital  deafness  has  also  its  significance.  So,  too,  have  hereditary 
forms  of  migraine  and  neuralgia.  Certain  defects  or  excesses  in  general 
cutaneous  sensibility  have  been  noted  as  frequent  among  degenerates. 
Thus    several    excellent  writers  on   this  subject   have   stated   that   a 


Fig.  302. — Hypertrichosis  in  a  female  imbecile. 


712  3IENTAL   DISEASES. 

general  anesthesia  is  not  uncommon,  especially  among  lower  classes 
of  degenerates.      In  some  instances  there  is  hyperesthesia. 

Anomalies  of  Speech. — It  may  be  questionable  as  to  how  far 
stammering  and  stuttering  are  to  be  looked  upon  as  functional  degen- 
erative stigmata,  but  they  are  certainly  found  more  often  in  children 
with  a  neuropathic  inheritance  than  in  children  with  good  heredity. 
Delay  in  the  acquisition  of  language  and  complete  or  partial  defect  of 
speech  have  more  significance. 

Anomalies  of  Genito-urinary  Function. — Sexual  irritability, 
impotence,  sterility,  and  urinary  incontinence  must  be  considered  as 
indices  of  neuropathic  disposition.  Retardation  of  puberty  in  both 
sexes,  but  especially  in  the  male  sex,  is  a  noteworthy  indication. 

Anomalies  of  Instinct  or  Appetite. — It  has  been  pointed  out 
that,  among  all  degenerates,  there  is  a  taste  or  appetite  for  certain  foods 
or  drugs  which  tends  to  favor  their  dissolution  (alcohol,  morphin, 
cocain,  and  the  like).  In  many  cases  of  inebriety  the  uncontrollal)le 
appetite  is  to  be  looked  upon  as  a  functional  stigma  of  neuropathic 
inheritance.  Gluttony,  merycism,  and  the  like  are  usually  similar  indi- 
cations. 

Miscellaneous. — A  diminished  resistance  against  external  influ- 
ences (such  as  strains  of  various  kind)  and  diseases  is  significant. 
Great  precocity  of  intellectual  development  and  of  certain  aptitudes, 
and  morbid  emotional  conditions,  are  among  suspicious  indications  of  a 
neuropathic  basis. 

The  psychic  stigmata  of  degeneracy  need  only  the  foregoing  enu- 
meration. 


PHYSICAL  AND  MENTAL  STRAIN. 

At  the  beginning  of  this  chapter  I  spoke  of  the  etiology  of  insanity 
as  being  describable  in  two  terms,  heredity  and  strain — heredity,  wdiich 
renders  the  nervous  organization  unstable,  the  strain,  which  causes  the 
unstable  nervous  centers  to  collapse.  Doubtless  there  are  limits  of  en- 
durance in  any  organization,  no  matter  how  strongly  balanced,  if  tlie 
strain  be  great  enough,  but  the  instances  of  insanity  developing  in  indi- 
viduals with  properly  balanced  and  adjusted  ner^'ous  organizations  are 
rare  indeed.  The  strain  which  breaks  the  unstable  nervous  system  is 
physical  or  moral,  often  both.  What  organism  could  withstand  the 
assaults  upon  its  integrity  of  all  three  of  these  foctors — heredity, 
physical  ill-health,  and  cankering  care?  It  is  difficult  to  estimate 
accurately  the  proportion  of  one  cause  as  comj)ared  with  another,  since 
usually  several  are  associated  in  the  same  case ;  but  I  believe  that 
statistics  will  support  me  in  the  statement  that  the  physical  causes  (in 
which  I  include  alcohol,  liodily  diseases  and  disorders,  accident  and  in- 
jury, old  age,  the  puerperal  state,  the  menopause,  and  the  like)  surpass 
the  moral  causes  (grief,  domestic  trouble,  business  worry,  overwork, 
religious  excitement,  love  affairs,  fright,  nervous  shock,  etc.)  as  factors 
in  insanity  by  about  two  to  one — that  is,  twice  as  many  are  made  in- 
sane by  physical  strain   as  by  mental  strain.      It  now  behooves  us  to 


GENERAL   ETIOLOGY  OF  INSANITY.  713 

examine  these  clivers  stresses,  and  to  show  how  some  of  them  give  a 
special  color  or  character  to  th(!  psychosis  dcvelopech  It  is  best  to  pre- 
sent them  somewhat  in  the  order  of  their  freqnency,  nnder  two  or  three 
categories,  the  most  connnon  and  most  important  first,  the  rarest  last. 
The  physical,  physiological,  and  moral  causes,  then,  will  be  considered  in 
the  following  order  : 

Physical  : 

1.  Toxic  (autotoxins,  alcohol,  narcotics,  metallic  poisons,  etc.). 

2.  Bodily  diseases  and  disorders  (syphilis,  acute  and  chronic  diseases  of 

the  nervous  system). 

3.  Trauma  to  the  head. 

4.  Nervous  exhaustion. 

Physiological  : 

1.  Puberty. 

2.  Puerperal  state. 

3.  Menopause. 

4.  Senility. 

Moral : 

1.  Emotional  strain. 

2.  Imitation. 

Toxic  Influences. — It  is  not  surprising  that  deleterious  agents  in 
the  blood,  which  bathes  every  cell  and  fiber  of  the  nervous  system, 
carrying  thither  the  necessary  nutritional  elements  and  removing 
thence  the  waste  products,  should  readily  overstimulate,  retard, 
pervert,  or  destroy  its  high  functions.  Some  of  these  agents  (like 
alcohol)  also  affect  the  nutrition  of  the  central  nervous  system,  by  in- 
ducing disease  of  the  arteries  and  of  the  stomach,  liver,  and  kidneys. 
Some  of  the  poisons  cause  insanity  by  long-continued  chronic  action 
upon  the  nervous  system,  and  others  by  acute  intoxication. 

Auto-intoxication. — Accumulation  of  deleterious  agents  in  the 
blood  in  such  quantity  as  to  affect  the  nervous  system — e.  g.,  carbonic 
acid  and  the  poison  of  diabetes  and  of  uremia — has  been  long  known  to 
medical  science  ;  but  the  more  mysterious  poisons  produced  by  disease 
in  various  parts  of  the  body,  by  fermenting  or  putrefying  substances  in 
the  alimentary  tract,  and  by  some  of  the  acute  infectious  fevers,  have 
only  of  late  taken  an  important  place  in  the  etiology  of  the  psychoses. 
We  do  not  yet  know  how  frequently  auto-intoxication  from  absorption 
of  intestinal  poisons  determines  insanity,  but  the  facts  thus  far  collected 
point  to  the  origin  of  a  considerable  number  of  cases  from  this  cause. 
These  cases  are  usually  of  depressed  type,  but  sometimes  maniacal. 

Alcohol. — While  the  position  of  autotoxemia  as  a  factor  in  etiology 
is  not  yet  determined,  we  may  say  of  alcohol  that  it  stands  foremost 
(after  heredity)  as  a  single,  independent  cause  (eighteen  to  twenty  per 
cent,  in  males).  Acute  alcoholism  rarely  induces  a  psychosis.  Alcoholic 
insanity  commonly  develops  from  chronic  alcoholism,  from  the  excessive 
use  of  the  poison  for  a  long  period  of  time.  It  is  three  or  four  times 
as  frequent  as  a  factor  in  the  insanity  of  males  as  of  females.  Usually 
it  is  not  difficult  to  discover  the  cause  of  an  alcoholic  insanity, 
but,  should  alcoholic  abuse   be   denied,  an  investigation  of  the  condi- 


714  MENTAL  DISEASES. 

tion  of  the  viscera  will  often  throw  light  upon  the  subject  (cirrhosis 
of  the  liver,  fatty  heart,  chronic  gastric  catarrh  with  heavily  furred 
tongue,  chronic  nephritis,  and  arteriosclerosis).  Corroborative  evidence 
will  generally  be  afforded,  too,  by  affections  of  the  nervous  system 
(alcoholic  polyneuritis  ;  alcoholic  epilepsy ;  muscular  paresis  here  and 
there  in  the  hands,  face,  or  tongue ;  fibrillary  tremor  of  the  face  and 
tongue,  fine  or  coarse  tremor  of  the  fingers  and  hands  ;  paresthesias, 
hvperesthesias,  neuralgias  ;  muscse  volitantes,  tinnitus  aurium,  ambly- 
opia, and  visual  hallucinationsj.  The  peculiar  psychic  degeneration  of 
alcoholism  is  very  characteristic.  This  consists  of  gradually  weakening 
memory  and  will,  slowness  of  perception  and  judgment,  and  loss  of 
esthetic  and  moral  sense,  with  occasional  states  of  depression  and  ac- 
cesses of  anger.  The  psychoses  which  develop  upon  this  basis  are 
marked  by  two  or  three  features,  which  are  considered  rather  pathogno- 
monic : 

1.  Often  a  peculiar  loss  of  the  sense  of  time  and  place  (a  paramnesia). 

2.  A  tendency  to  illusions  and  hallucinations,  innumerable,  changing, 
mobile,  and  variegated. 

3.  A  tinge  of  weak-mindedness  in  the  psychic  symptoms  presented. 
Hvsterical  manifestations  are  not  uncommon  in  alcoholic  insanity. 
Morphin. — ]\Iorphin   is,   among  the   alkaloids,   the   most   frequent 

cause  of  insanity.  It  is  a  sad  commentary  on  the  heedlessness  of  some 
medical  men,  but  the  family  physician  is  responsible  in  almost  every 
case  of  development  of  the  morphin  habit  and  its  far-reaching  conse- 
quences. It  should  be  looked  upon  as  a  sin  to  give  a  dose  of  morphin 
for  insomnia  or  for  any  pain  (such  as  neuralgia,  dysmenorrhea,  rheuma- 
tism) which  is  other  than  extremely  severe  and  transient.  The  earliest 
symptom  of  morphinism  is  a  general  sensation  of  disquiet,  manifested 
by  incoherence  of  thought,  difficult}^  of  concentration  of  the  mind, 
marked  motor  restlessness,  and  insomnia.  The  dose  is  gradually  in- 
creased, and  may  reach  a  maximum  of  five  or  more  grams. 

The   chief  physical   disorders    induced  by   long-continued    use    of 
morphin  or  opium  are  as  follows  : 

1.  Anorexia  and  constipation  (later,  diarrhea  often). 

2.  Cachectic  anemia. 

3.  Cardiac  weakness  and  intermittence,  and  bradycardia. 

4.  Muscular  weakness  with  tremor. 

5.  Miosis  in  the  early  stages,  mydriasis  later,  with  sluggish  re- 
action of  the  pupils. 

6.  Impotence.     Amenorrhea  in  women. 

7.  The  knee-jerks  are  often  absent. 

8.  Diminished  sensibility  to  touch  and  pain,  and  concentric  limi- 
tation of  the  visual  fields. 

9    Headaches  and  localized  shooting  pains,  neuralgias,  and  pares- 
thesias. 

10.  Sensation  of  feeling  cold. 

The  psychic  symptoms  may  be  summarized  briefly,  thus  : 
1.  Simple  elementary  illusions  and  hallucinations,  muscse  volitantes, 
tinnitus  aurium. 


GENERAL   ETIOLOGY  OF  INSANITY.  715 

2.  Loss  of  will  and  esthetic  sense,  irritability  ;  moral  perversion,  as 
in  alcoholic  psychic  degeneration,  but  with  little  failure  of  memory, 

3.  Diminished  attention,  incoherence  of  ideas,  and  easily  fatigued 
intellectual  powers. 

A  well-developed  psychosis  is  usually  the  result  of  abstinence  from 
morphin,  and  not  of  the  chronic  misuse  of  it.  It  varies  in  degree  up 
to  a  type  approaching  acute  mania. 

Cocain. — Of  recent  years  there  have  been  numerous  instances  of 
cocain  insanity,  and  they  are  doubtless  growing  more  frequent.  While 
with  morphin  it. is  the  abstinence  that  is  prone  to  induce  a  psychosis, 
with  cocain,  on  the  contrary,  it  is  the  prolonged  use  of  the  drug  that 
develops  the  insanity,  while  abstinence  gives  rise  to  few  noteworthy 
symptoms.  The  misuse  of  cocain  leads  to  the  evolution  of  an  acute 
hallucinatory  paranoia. 

Hashish  (Cannabis  Indica). — We  never  see  insanity  from  this 
cause  in  America,  but  in  Egypt  and  India  it  is  extremely  common.  In 
visits  paid  by  the  writer  to  the  Cairo  Insane  Asylum  in  the  winter  of 
1891-92,  he  observed  64  cases  of  the  248  patients  in  the  institution 
in  which  the  insanity  was  due  to  the  inhalation  of  hashish  by  smoking. 
The  symptoms  produced  are  indigestion,  diarrhea,  increased  appetite, 
dilatation  of  the  pupils,  drooping  eyelids,  anemia,  general  debility,  and 
delirium.  The  earliest  mental  symptom  is  marked  and  increasing 
timidity,  sometimes  amounting  to  folie  dii  chute,  or  an  agoraphobia. 

Atropin  ;  Hyoscyamin  ;  Hyoscin. — These  isomeric  alkaloids  have 
much  the  same  physiological  effects  (mydriasis,  paralysis  of  accommo- 
dation, dryness  of  the  throat,  depressed  heart's  action,  dreadful  illusions 
and  hallucinations,  etc.),  but  instances  are  not  common  of  their  giving 
rise  to  psychoses.  However,  it  is  probable  that  the  employment  of  one 
of  these  as  a  secret  cure  for  drunkenness  has  been  the  cause  of  serious 
insanity  in  a  considerable  number  of  cases  that  have  found  their  way 
from  sanatoriums  to  asylums.^ 

Metallic  Poisons. — Lead  and  mercury  at  times  induce  insanity,  the 
former  much  more  frequently  than  the  latter.  The  intoxication  is 
chronic,  but  the  psychosis  developed  may  be  either  acute  or  chronic. 
Both  of  these  poisons  produce  similar  psychic  symptoms,  such  as  ver- 
tigo, sleeplessness,  rudimentary  or  marked  hallucinations,  confusion  and 
incoherence,  anxious  depression,  and  often  persecutory  delusions.  In 
severe  cases  there  is  dementia.  In  lead  cases  there  are  usually  to  be 
observed  the  concomitant  physical  symptoms,  such  as  anemia,  colic, 
blue  line  on  the  gums,  tremor,  arthralgia,  palsies,  and  convulsions.  In 
mercury  cases  we  note  stomatitis,  tremor,  and  gastro-intestinal  catarrh. 
Hysterical  symptoms  are  not  infrequently  superadded  upon  the  lead 
and  mercury  psychoses. 

Various  Poisons. — There  are  many  other  poisons  which,  in  rare 
instances,  produce  insanity.  Among  these  may  be  mentioned  coal-gas, 
carbonic  ox  id,    stramonium,  henbane,  hemlock,   bisulphid    of   carbon, 

^  Dr.  B.  D.  Evans,  Superiatendeut  of  the  Morris  Plains  Asylum,  N.  J.,  has  col- 
lected a  number  of  such  cases. 


716  MENTAL   DISEASES. 

etc.  The  writer  described  some  years  ago  three  cases  of  bisulphid  of 
carbon  insanity  which  ran  their  course  under  the  tyjje  of  acute  mania 
going  on  to  recovery,  studied  by  him  at  the  Hudson  River  State 
Hospital  for  the  Insane.  ^  All  three  were  workers  in  a  ruljber 
factory. 

Bodily  Diseases  and  Disorders. — Syphilis. — Syphilis  is  one  of 
the  most  important  of  the  physical  causes  of  insanity.  It  acts  upon 
the  brain  indirectly  through  Avide-spread,  severe  disturbance  of  general 
nutrition  and  through  arteriosclerosis,  and  directly  by  the  production 
of  diffuse  changes  in  the  tissues  of  the  central  nervous  system,  or  of 
circumscribed  meningeal  deposits  or  intracerebral  gummata.  The  degen- 
eration of  cells  and  fibers,  the  gliosis  and  the  arteriosclerosis,  are  possibly 
due  to  toxins  created  by  specific  micro-organisms,  and  not  to  the  direct 
influence  of  the  germs  themselves,  which  may  explain  why  syphilitic 
psychoses  are  ordinarily  late  manifestations  of  syphilis.  General 
paralysis  and  cerebral  syphilis  are  the  chief  phases  in  which  the  psy- 
chosis is  presented.  It  is  often  difficult  to  obtain  a  history  of  syphilis 
in  a  patient,  so  that  the  statistics  as  to  the  frequency  of  syphilis  as  a 
cause  of  general  paresis,  for  instance,  are  generally  faulty.  AVhere  the 
history  is  uncertain,  a  careful  examination  may  indicate  the  existence 
of  syphilis  (hereditary  syphilis  in  the  children,  leukoderma,  cicatrices, 
swelling  of  the  lymph-glands,  periosteal  deposits  and  tophi,  perforation 
of  the  palate,  nasal  symptoms,  etc.). 

Hereditary  syphilis  plays  a  part  in  the  etiology  of  the  psychoses  of 
early  life, — for  example,  imbecility  and  idiocy, — though  probably  not 
so  great  a  part  as  is  frequently  asserted,  for,  in  a  considerable  experience 
with  such  conditions  at  the  Randall's  Island  Asylum  for  Idiots,  I  liave 
seen  but  little  hereditary  syphilis. 

Acute  Infectious  Diseases. — Typhoid  fever,  malaria,  pneumonia, 
influenza,  and  acute  articular  rheumatism  head  the  list  of  acute  fevers 
which  sometimes  superinduce  insanity.  Disturbances  of  nutrition, 
high  fever,  and  toxic  changes  in  the  blood  are  responsible  for  the 
symptoms  developed.  Perhaps  the  toxin-producing  bacteria  are  the 
chief  agents,  acting  by  direct  influence  upon  the  cortical  cells  and  fibers. 
If  this  be  true,  these  cases  were  better  classed  under  the  head  of  Toxic 
Influences.  At  the  height  of  a  fever  we  have  a  febrile  delirium,  char- 
acterized by  hallucinatory  incoherence  ;  but,  later  on,  when  the  fever  has 
diminished  and  the  organism  is  weakened  by  disease,  such  manifestation 
is  termed  "  inanition  delirium."  From  either  the  febrile  or  inanition 
delirium  a  psychosis  may  develop,  usually  assuming  the  type  of  a  hallu- 
cinatory paranoia  with  self-depreciatory  or  persecutory  delusions,  in 
some  cases  with  a  tendency  to  agitation,  in  others  with  inclination  to  a 
stuporous  condition.  Mania  and  melancholia  are  rare,  stupidity  with  a 
proclivity  to  terminal  dementia  more  common.  ISIalarial  psychoses 
sometimes  exhibit  a  certain  periodicity  corresponding  to  the  intermittent 
nature  of  the  cause.  Heredity,  alcoholic  degeneration,  etc.,  also  play 
a  considerable  part  in  the  etiology  of  this  form  of  toxic  mental  disorder. 

1  "Boston  Med.  and  Surg.  .Jour.,"  Oct.,  1892. 


GENERA  L   ETIOLOG  Y  OF  INS  A  NITY.  717 

Tuberculosis. — The  disturbances  of  nutrition  in  tuberculosis,  as 
well  as  tlie  mental  depression  sometimes  associated  with  the  disease, 
occasionally  lead  to  the  develoj)nient,  out  of  an  exhaustion  or  inanition 
delirium,  of  a  true  psychosis — a  melancholia  or  a  hallucinatory  excite- 
ment. It  may  be  said,  however,  that  the  relation  of  tuberculosis  to 
insanity  is  nuich  more  frequently  that  of  sequel  than  of  prodrome,  for 
many  cases  of  melancholia  and  stuporous  forms  of  insanity  die  of  this 
disease  owing  to  shallow  respiratory  functions  and  insuiiicient  nutrition. 

Carcinoma. — The  progressive  cachexia  induced  by  malignant  dis- 
ease, as  well  as  the  direct  efl'ects  of  cerebral  metastases,  sometimes  lead 
to  psychopathic  conditions  resembling  those  of  tuberculosis. 

Heart  Disease  and  Atheromatous  Arteries. — Cardiac  disease  is 
frequently  found  among  the  insane,  but  its  precise  relation  to  the 
psychoses  is  obscure.  Doubtless,  in  so  far  as  it  disturbs  the  circulation 
and  interferes  with  cerebral  nutrition,  it  predisposes  to  mental  instability. 
On  the  other  hand,  disease  of  the  arteries  (senile,  nephritic,  syphilitic, 
alcoiiolic,  cachectic),  is  a  much  more  eifective  disturber  of  nutrition, 
and  at  the  same  time  gives  rise  to  serious  focal  lesions,  such  as  miliary 
aneurysms,  thrombosis,  and  hemorrhage,  which  may  be  etiologically 
associated  with  various  psychopathies. 

Nephritis. — The  nephritic  psychoses  assume  usually  the  type  of  a 
hallucinatory  paranoia,  and  therein  resemble  other  toxic  insanities.  It 
is  probable  that  toxic  changes  in  the  blood  are  here  of  more  importance 
than  the  changes  in  the  vascular  walls,  though  these,  too,  have  their 
significance. 

G-astro -intestinal  Disorders. — These  sometimes  induce  hypochon- 
driacal melancholia,  and  predispose  to  psychoses  of  various  kinds  by 
disturbing  nutrition  ;  but  their  frequent  relation  to  insanity  is  generally 
a  consequence  rather  than  a  cause. 

Diseases  of  the  Genital  Org-ans. — There  are  serious  disorders  of 
the  female  genital  organs  which  occasionally  play  a  role  in  the  causa- 
tion of  insanity,  but  their  importance  as  factors  has  been  grossly 
exaggerated,  and  much  harm  and  little  good  have  followed  operative 
interference  for  the  relief  of  the  insanity.  Probably  the  cessation  of 
menstruation  (usual  in  acute  insanities)  has  been  misinter^jreted  as 
significant  of  genital  disease,  and  thus  given  rise  to  a  grave  error. 

I  woidd  not  be  understood  as  decrying  operative  or  other  treatment 
altogether,  if  such  be  indicated  ;  but  let  no  one  be  deceived  into  expect- 
ing benefit  from  the  procedures,  except  in  rare  instances. 

Having  briefly  examined  most  of  the  general  physical  disorders 
which  are  concerned  in  the  causation  of  insanity,  we  will  now  turn  our 
attention  to  certain  functional  diseases  of  the  nervous  system  which,  by 
reason  of  their  localization  in  the  cerebral  cortex,  are  prone  to  assume 
a  very  important  part  in  psychopathology.  These  are  epilepsy,  hysteria, 
and  chorea. 

Epilepsy. — Epilepsy  is  almost  as  common  a  disease  as  insanity 
itself.  Asylum  physicians,  whose  experience  with  epilepsy  is  limited  to 
cases  associated  with  mental  disorder,  tend  to  overestimate  the  frequency 
of  insanity  among  epileptics.     Thus,  it  is  often  stated  by  them  that  psychic 


718  MENTAL  DISEASES. 

degeneration  is  manifested  in  sixty  to  eighty  per  cent,  of  all  epileptics. 
But  the  fact  is  that  probably  not  more  than  ten  to  fifteen  per  cent,  of 
epileptics  develop  insanity ;  at  the  same  time  the  proportion  is  so  large 
as  to  show  a  close  relation  between  this  functional  cortical  malady  and 
mental  disorders.  When  progressive  epileptic  degeneration  occurs,  it 
manifests  itself  by  the  following  symptoms  : 

1.  Slowness  of  ideation  and  articulation. 

2.  Abnormal  irritability  of  temper. 

3.  Hypochondriacal  depression. 

4.  Paranoid  outbreaks  of  various  kinds. 

5.  Dementia. 

Hysteria. — Hysteria  is  also  a  functional  neurosis  of  the  cortex, 
often  closely  associated  with  divers  psychoses.  There  is  a  species  of 
hysterical  psychic  degeneration,  and  the  neurosis  frequently  gives  a 
special  color  to  different  forms  of  insanity.  The  symptoms  noted 
(aside  from  the  peculiar  sensory  and  motor  manifestations  familiar  to  us 
in  simple  hysteria)  on  the  mental  side  are  as  follows  : 

1.  Lack  of  logical  coherence  and  sequence  of  thought,  but  with 
perfect  intelligence.  Defects  of  memory,  with  rudimentary  persecutory 
and  erotic  delusions,  are  encountered  frequently. 

2.  Extreme  uncontrolled  and  morbidly  changeable  emotions.  Pro- 
found egotism. 

3.  Frequent  illusions  ;  occasional  hallucinations. 

4.  Conduct  and  speech  are  based  upon  emotional  impulsiveness,  un- 
controlled by  ethical  considerations  of  any  kind. 

Organic  Nervous  Diseases. — -The  psychic  disorders  induced  by 
organic  processes  in  the  brain,  such  as  meningitis,  tumor,  softening, 
hemorrhage,  and  the  like,  are  characterized  either  by  symptoms  of  re- 
tardation of  functions  or  by  symptoms  of  irritation,  and  are  due  either 
to  pressure  or  to  the  indirect  influence  of  the  lesion  upon  the  circula- 
tion or  nerve-centers  and  tracts.  Emotional  irritability,  hallucinations 
of  the  various  senses,  defects  of  intelligence  reaching  to  imbecility  or 
idiocy,  stuporous  conditions — these  are  common  mental  manifestations 
of  such  processes.  Since  single  localized  lesions  are  apt  to  produce  slight 
mental  changes,  any  marked  intellectual  defect  or  multiform  psychic 
symptoms  may  be  looked  upon  as  suggestive  of  wide-spread,  perhaps 
multiple,  lesions,  such  as  multiple  sclerosis,  multiple  tumors,  syphilis, 
etc.  Sometimes  true  insanities  develop  in  these  cases,  particularly 
when  there  is  hereditary  instability  of  nervous  organization. 

Trauma  to  the  Head. — A  blow  upon  the  head  is  one  of  the  most 
direct  of  stresses  to  which  the  brain  can  be  subjected.  It  is  not  so 
much  the  local  eifect  of  the  injury  (which,  indeed,  would  not  present 
psychic  symptoms  differing  materially  from  those  of  any  other  local 
lesion  of  the  brain  such  as  have  just  been  considered),  but  the  general 
eflFect  of  a  commotio  cerebri  that  we  are  called  upon  to  consider.  The 
syndrome  of  mental  disorders  induced  by  such  cause  has  been  well 
termed  by  the  Germans  "  commotion  insanity."  The  eifect  of  a  violent 
blow,  jar,  or  jolt  to  the  head  must  have  some  influence  upon  the  mole- 
cules of  the   brain  as  well  as  upon  the  encephalon  as  a  mass,  must  dis- 


GENERAL   ETIOLOGY  OF  INSANITY.  719 

place  and  disarrange  delicate  microscopic  structures,  such  as  the  cells 
and  fibers.  If  the  blow  be  insufficient  to  produce  complete  loss  of  con- 
sciousnesSj  there  will  be  a  dazed,  bewildered  condition,  and  the  patient 
will  struggle  or  grope  about  in  a  confused  way.  There  may  be  a  loss 
of  memory,  more  or  less  extensive,  as  a  result.  Xaturally,  the  newest 
organizations  of  tissues,  being  the  most  fragile,  will  be  the  most  easily 
disarranged ;  hence,  with  amnesic  defects,  it  will  be  the  most  recent 
acquisitions,  or  such  as  cluster  about  the  time  of  the  injury,  which  will 
suifer  most.  The  patient  will  experience  strange  sensations  in  his 
head.  The  head  may  feel  as  if  it  were  going  around.  Objects  seem 
to  move.  There  is  a  feeling;  of  beino-  intoxicated  or  of  dizziness.  A 
general  hyperesthesia  and  hyperalgesia  are  not  uncommon,  while  a 
hypalgesia  is  occasionally  observed.  Among  psychic  symptoms  hallu- 
cinations and  painful  effects  are  prominent,  generally  of  a  terrifying 
nature.  Associations  may  be  so  interfered  with  as  to  induce  difficult 
ideation,  mental  confusion,  and  a  genuine  primary  incoherence.  The 
motor  expressions  are  often  characteristic,  consisting  of  catatonic  con- 
ditions, impulsive  acts  of  violence,  and  aimless  wandering  about.  In 
some  cases  no  particular  results  of  the  trauma  are  noted  until  the  lapse 
of  a  few  hours  or  days,  when  suddenly  the  traumatic  psychosis  de- 
velops. After  the  psychosis  has  run  an  acute  course,  a  condition  of 
chronic  insanity  or  of  a  secondary  dementia  may  follow.  Such  a 
secondary  dementia  may  simulate  very  closely  general  paresis,  particu- 
larly if  it  be  progressive.  It  can  not  be  said  that  there  are  any  well- 
authenticated  cases  of  true  general  paralysis  dependent  upon  trauma- 
tism. 

There  are  not  infrequently  instances  of  the  creation,  by  trauma  to 
the  head  which  has  induced  no  direct  evil  consequences,  of  an  unstable 
nervous  system,  of  a  predisposition  upon  which  other  etiological  factors 
may  operate  later  in  life. 

Insolation  probably  acts  upon  the  brain  in  a  manner  similar  to  trau- 
matism. 

Nervous  Exhaustion. — Stresses  of  various  kinds,  mental  or  phys- 
ical, especially  in  conjunction  with  the  impairment  of  the  nutrition  of 
the  central  nervous  system,  induce  an  exhaustion  upon  the  basis  of 
which  a  psychosis  may  develop.  The  mental  strain  may  be  from  over- 
work, overstudy,  insomnia,  and  the  like  ;  the  physical  from  masturba- 
tion, sexual  excess,  hardships.  The  nutritive  impairment  is  the  result 
of  some  blood-change  or  deficiency,  such  as  constitutional  anemia,  a 
cachectic  state,  etc.  The  physical  symptoms  of  such  exhaustion  are  : 
slowing  of  the  thought  processes,  difficulty  of  recollection,  want  of 
ability  to  concentrate  the  attention,  rapid  fatigue  on  mental  exertion, 
emotional  irritability  with  an  undertone  of  depression,  leading  often  to 
fully  developed  insanities,  which  are  designated  as  asthenic  psychoses. 
The  common  features  of  such  psychoses  are  retardation  and  incoherence 
of  the  mental  processes,  manifested  even  in  the  quality  of  the  halluci- 
nations and  delusions.  But  almost  any  form  of  insanity  may  be  evolved 
from  this  asthenic  state  of  the  nervous  system,  such  as  mania,  neuras- 
thenia, stuporous  states,  and  various  types  of  paranoia. 


720  MENTAL  DISEASES. 

As  Ziehen  points  out,  it  is  also  interesting  to  observe  how  any  ex- 
hausting psychosis  may  in  itself  induce  this  asthenic  condition  with  the 
characteristic  features  of  an  asthenic  psychosis,  as  a  result  of  which  we 
liave  a  secondary  type  of  mental  disorder  developed  upon  the  basis  of 
the  original  insanity. 

Physiological  Factors. — Puberty,  the  puerperal  state,  the  climac- 
teric, and  senility  are  indirect  strains  to  which  the  organism  is  subject, 
by  reason  of  the  more  or  less  profound  physiological  commotions  they 
arouse  in  the  nervous  system — commotions  which  may  well  disturb  the 
normal  adjustment  and  equipoise  of  the  thousands  of  delicate  processes 
going  on  in  the  brain,  and  thus  enormously  increase  its  vulnerability  to 
the  direct  factors  which  beget  insanity. 

The  curve  of  psychic  morbidity  reaches  its  highest  points,  corre- 
sponding to  maximal  aggregations  of  etiological  factors  in  both  sexes,  at 
puberty,  middle  age,  puerperal  periods,  the  climacteric,  and  senility. 

Puberty. — From  the  thirteenth  to  the  twentieth  year  there  are  re- 
markable changes,  physical  and  mental,  in  the  growing  individual. 
These  are  more  noteworthy  in  the  female  than  in  the  male  sex,  for  the 
time  is  shorter  for  the  change  from  girlhood  to  womanhood  than  from 
boyhood  to  manhood.  The  evolution  of  the  sexual  characters  and  the 
development  of  the  powers  of  reproduction  induce  a  stream  of  innu- 
merable new  stimuli  from  the  genital  organs  to  the  brain,  accompanied 
by  wholly  new  organic  sensations,  new  associations,  and  new  and  power- 
ful emotions.  The  evolution  is  rapid,  and,  as  is  the  case  with  all  rapid 
development,  more  or  less  unstable. 

The  boy  grows  fast  in  body,  takes  on  the  aspect  of  manhood,  with 
a  stronger  and  more  rugged  frame,  a  changing  voice,  a  budding  beard. 
His  mind  is  filled  with  new  sensations,  emotional,  sentimental,  amatory, 
and  with  changing,  fantastic,  illusory  dreams  and  imaginings.  Even  in 
the  normal  youth  this  nascent  state,  this  struggle  of  the  emotions, 
thoughts,  instincts,  impulses  for  new  associations  and  new  combinations, 
may  be  greatly  aggravated  in  many  cases  by  masturbation,  in  others  by 
nutritive  disorders.  If  this  be  so  with  the  normal  individual,  how 
much  greater  must  be  the  stress  of  puberty  to  the  individual  with  a 
constitution  vitiated  ])y  hereditary  taint ! 

The  girl  leaps  more  quickly  into  her  place  in  life.  The  physical 
changes  are  more  rapid  in  her,  and  at  the  same  time  more  varied  and 
noteworthy.  It  is  a  time  of  tumultuous  activity  of  mind  and  body  in 
an  organism  which  has  not  the  numerous  outlets  for  surplus  energy 
possessed  by  the  other  sex. 

The  psychoses  of  puberty  are  various  in  their  expression.  They 
may  manifest  themselves  as  a  mania,  a  melancholia,  a  paranoia,  or  as  an 
insanity  with  peculiar  color,  to  which  the  name  hebephrenic  modification 
has  been  given  ;  so  that  we  speak  of  a  hebephrenic  mania,  a  hebephrenic 
melancholia,  etc. 

By  the  designation  hebephrenic  is  understood  the  following  syn- 
drome :  Extraordinarily  rapid  and  paradoxical  changes  (depressed  ideas 
in  the  midst  of  boisterous  gaiety,  jocularity  in  the  deepest  def)ression), 
with    paradoxical    facial    expression    and    paramimia ;     exalted    motor 


GENERAL   ETIOLOGY  OF  INSANITY.  721 

activity  (laugliing,  clancing,  grimacing;,  exhorting  after  the  manner  of 
an  orator,  often  witli  inc()nij)r('liensibh'  words  and  sentences)  ;  conduct 
and  action  witliout  apparent  object,  but  often  with  the  semblance  of 
desiring  to  attract  attention. 

Puerperal  State. — Pregnancy,  parturition,  and  lactation  diminish 
the  vitality  of  woman,  debilitate  and  weaken  her  entire  organism, 
induce  a  species  of  physiological  commotion  in  her  nervous  system,  and, 
in  short,  bring  to  bear  a  strain  upon  her  which  is,  even  under  normal 
conditions,  attended  by  emotional  irritability,  depression,  morbid  yearn- 
ings, etc.  It  is  not  strange,  therefore,  that  the  puerperal  period  in 
women  with  unstable  nervous  systems  should  often  be  an  exciting  factor 
in  the  development  of  psychoses  of  various  kinds.  In  about  ten  per 
cent,  of  insane  women  the  insanity  has  its  origin  at  the  epoch  of  repro- 
duction. The  majority  of  these  cases  are  parturitional  (seven  and  a 
half  per  cent.),  while  about  a  fourth  are  lactational  and  a  tenth  preg- 
nancy cases.  It  is  perhaps  true  that  there  are  many  cases  of  partu- 
ritional psychoses  in  which  the  insanity  is  not  so  much  due  to  the  stress 
of  labor  as  to  possible  auto-intoxications  from  poisonous  substances 
absorbed  during  the  catabolic  changes  incident  to  subinvolution  of  the 
enlarged  uterus.  As  important  factors,  too,  we  must  include  loss  of 
blood,  parametritis,  sepsis,  mastitis,  etc. 

There  are  divers  forms  of  insanity  consequent  to  the  puerperal  state, 
such  as  acute  hallucinatory  paranoia,  melancholia,  stuporous  insanity, 
mania,  and  neurasthenic  insanity. 

Menopause. — The  climacteric,  between  the  ages  of  forty  and  fifty, 
is  another  epoch  of  change  in  woman,  a  period  of  involution  in  its  way 
analogous  to  the  evolution  at  the  age  of  puberty.  There  is  a  physio- 
logical commotion  in  the  nervous  system  at  the  time  of  the  cessation 
of  ovulation  and  menstruation,  a  disequilibration  associated,  even  in 
normal  individuals,  with  numerous  neurotic  manifestations,  and,  in  such 
as  have  unstable  organizations,  attended  with  peril  to  the  mental  in- 
tegrity. Melancholia,  simple  and  hallucinatory  paranoia  of  chronic 
character,  and  circular  insanity  are  the  forms  of  psychosis  incident  to 
the  menopause.  About  four  per  cent,  of  the  cases  of  insanity  in  women 
are  due  to  the  climacteric. 

Senility. — The  involution  of  all  the  tissues  of  the  body  characteristic 
of  especially  the  seventh  decad  of  life  forms  also  a  frequent  basis  for 
insanity  which  depends,  in  the  main,  upon  the  loss  of  functional  activity 
in  the  cerebral  cortex.  Such  loss  is  notable  even  in  normal  individuals. 
The  latest  acquisitions  of  the  mind  are  the  least  stable  ;  hence  the  con- 
spicuous loss  of  memory  for  events  of  recent  occurrence  and  the  ten- 
dency to  live  in  the  past.  The  scope  of  interests,  sympathies,  and  ideas 
narrows  itself  down  to  the  individual's  immediate  physical  comfort  and 
needs.  While  the  physiological  involution  of  senility  belongs  to  the 
seventh  decad,  in  many  instances  it  begins  long  before  this,  owing  to 
general  debility,  endarteritis,  etc.  Marked  changes  in  the  brain  of 
such  nature  must,  therefore,  often  superinduce  veritable  psychoses  in 
individuals  predisposed  to  mental  disorder  by  heredity  or  by  antecedent 
physical  or  psychic  stresses. 
46 


722  3IENTAL   DISEASES. 

Senile  insanities  manifest  themselves  in  many  forms, — melancholia, 
mania,  incoherent  paranoia,  hallucinatory  paranoia,  dementia, — ^biit,  of 
course,  modified  from  the  common  types  by  the  weakening  of  the  cor- 
tical functions  previously  described.  Vertiginous  seizures,  slight  pare- 
ses,  dreadful  hallucinations,  and  primary  anxious  conditions  are  often 
observed  in  all  of  these  forms. 

The  hallucinations  appear  in  senile  forms  in  psychoses  which  ordi- 
narily run  their  course  without  them,  and  the  anxious  states  in  ordinarily 
non-aifective  insanities. 

Moral  Causes. — About  twenty-four  per  cent,  of  all  cases  of  insanity 
are  ascribed  to  moral  causes,  among  which  are  classed  domestic  troubles, 
grief  over  death  of  friends,  business  worries,  anger,  religious  excitement, 
love  affairs,  fright,  and  nervous  shock.  The  percentage  is  greater  in 
women  than  in  men.  It  is  doubtful  if  any  emotion  alone  can  overcome 
the  stability  of  the  normal  nervous  system ;  hence  it  is  in  the  fragile, 
nervous  constitutions  of  individuals  tainted  by  heredity  that  extreme 
emotions  are  wont  to  exert  their  malign  influence. 

The  uncertain  equilibrium  of  the  highest  nerve-centers  in  these  cases 
is  all  too  readily  overcome  by  the  tumultuous  wave  of  an  intense 
emotional  impression.  Possibly,  the  results  depend  upon  disturbance 
of  the  vascular  innervation.  Ordinarily,  the  greater  and  more  sudden 
the  emotion,  the  greater  the  liability  of  the  badly  poised  brain  to  suc- 
cumb ;  but,  like  the  drops  that  wear  away  the  stone,  an  emotion  of  less 
intensity  may,  by  long  continuance,  produce  equally  disastrous  conse- 
quences. Some  acute  psychoses  may  be  suddenly  developed  by  fright, 
or  a  transitory  emotional  insanity  for  a  few  hours  or  for  a  few  days  in 
duration.  Among  the  symptoms  are  mutism,  or  incoherence,  confusion, 
isolated  hallucinations,  delusions,  with  impulses  to  violence  and  aimless 
wandering,  followed  later  by  complete,  or  nearly  complete,  amnesia. 

The  more  slowly  working  aflPects,  like  sorrow  and  worry,  often  aid  in 
the  evolution  of  melancholia,  paralytic  dementia,  or  acute  or  chronic 
paranoia. 

Imitation. — The  so-called  psychic  infection  never  influences  normal 
individuals  who  are  brought  into  contact  with  the  insane.  Physicians, 
attendants,  and  others  who  have  to  do  with  the  insane  are  never 
aflected,  except  when  morbid  heredits^  and  mental  and  physical  over- 
work combine  to  prepare  the  soil  for  the  development  of  a  psychosis. 
The  writer  recalls  but  one  instance  of  an  attendant  being  mentally 
unbalanced  during  her  service.  She  was  neurotic  by  constitution  and 
cut  her  throat  a  few  days  after  one  of  her  patients  had  committed  sui- 
cide in  the  same  manner.  But  there  are  not  infrequent  instances  of 
communicated  insanity  among  members  of  a  family. 

The  simultaneous  development  of  insanity  in  two  or  more  persons 
associated  together,  or  the  imposition  of  delusions  gradually  arising  in 
the  mind  of  one  upon  the  impressionable  intellect  of  a  second,  third,  or 
of  many  persons,  has  been  described  under  the  names  Folic  a  Deux,  Folie 
Simultanee,  Reciprocal  Insanity,  Folie  Imposee,  etc.  There  are  several 
factors  which  govern  the  evolution  of  such  insanities.  In  both  forms  a 
degenerative   soil  is  usually  required  for   the  proper   germination  and 


GENERAL  ETIOLOGY  OF  INSANITY.  723 

growth  of  morbid  ideas.  In  the  simuUaneous  variety  there  must  be,  in 
addition  to  predisposition,  that  similarity  of  intellectual  substrata  which 
we  find  particularly  in  persons  who  are  blood-relations  or  who  are  inti- 
mately joined  together  by  mutual  like  and  dislike  ;  hence  it  is  that 
brothers  or  sisters  most  frequently  manifest  simultaneous  insanity. 
Take  two  healthy  children  of  one  lamily  and  bring  them  up  far  apart, 
yet  there  will  be  innumerable  physical  resemblances  between  them,  and 
many  peculiarities  in  their  character  and  conduct  which  prove  them  to 
be  consanguineous ;  if  a  hereditary  instability  of  nerve-cells  had  been 
implanted  in  them,  there  would  be  a  tendency  to  a  similar  form  of  dis- 
solution, even  if  they  remained  apart.  How  much  greater  would  this 
be  in  two  persons  so  intimately  associated  as  sisters,  for  instance.  In 
children  the  study  of  unconscious  imitation  is  one  of  great  interest. 
Who  has  not  observed  the  identity  of  intonation  of  phrases,  of  gesture, 
of  laughter,  of  many  facial  expressions,  of  certain  habits,  in  children 
either  related  or  brought  up  together  ?  Such  unconscious  imitation,  as 
is  well  known,  may  lead  in  children  to  the  contraction  of  certain  nervous 
and  even  mental  diseases.  The  contagious  quality  of  emotions  is  well 
established.  An  explosion  of  laughter  will  call  up  smiles  on  even 
melancholy  faces  in  a  crowd.  A  pathetic  scene  on  a  stage  will  bring 
tears  and  depress  the  oral  angles  in  a  large  audience.  The  unconscious 
imitation  of  gestures,  such  as  bowing,  often  seen  in  adults,  is  in  a  milder 
degree  such  mimicry  of  motion  as  is  observed  in  dancing  mania. 

Another  element  in  the  imposition  of  insanity  by  one  upon  another 
is  the  quality  of  the  morbid  mind-product.  If  a  delusion,  it  must  have 
an  air  of  probability  to  the  person  receiving  it,  and  must  be  gradually 
developed  and  imposed.  It  is  because  suspicion  is  inherent  in  the 
nature  of  most  persons,  because  suspicion  can  wear  so  much  probability 
of  truth,  that  persecutory  delusions  are  by  far  the  most  frequently 
adopted  by  others.  Credulity  is  an  important  factor  in  the  imposition 
of  insane  delusions  upon  others.  It  was  the  ready  credulity  of  large 
numbers  of  persons,  especially  as  regards  religious  subjects,  that  in 
the  past  led  hundreds  of  thousands  of  people  to  adopt  with  faith  the 
delusions  of  paranoiacs  like  John  of  Leyden,  John  Thom  of  Canterbury, 
Joan  of  Arc,  Richard  Brothers,  Joanna  Southcott,  John  Brown,  and 
many  others,  and  actually  to  sacrifice  their  lives  upon  the  altar  of  their 
beliefs.  Though  these  delusions  emanate  from  an  insane  person,  their 
acceptance  by  others  does  not,  of  course,  necessarily  imply  insanity  in 
the  latter,  for  delusions  of  this  character  have  their  support  in  the 
superstitions  of  many  and  in  ignorance  concerning  supernatural  matters. 
A  persecutory  delusion  might  be  imposed  by  an  insane  person  upon  an 
intimate  associate,  and  yet  the  latter  need  not,  of  necessity,  be  insane  ; 
but  when  the  exposed  individual  adopts  the  delusions,  regulates  his 
conduct  upon  them,  allows  them  to  become  rooted  in  his  mind,  even 
begins  to  share  the  hallucinations  of  his  friend,  there  is,  of  course,  actual 
aberration  of  mind  present.  Several  cases  of  folie  a  deux  have  come 
under  my  observation.  One  case  was  that  of  two  sisters,  aged  about 
fifty  to  fifty-five,  Irish,  Avasherwomen,  who,  living  alone  in  a  tumble- 
down shanty,   were  often  tormented  by  boys  throwing  stones  at  the 


724  MENTAL  DISEASES. 

house  at  night,  and  otherwise  teasing  them.  They  finally  developed 
persecutory  delusions  with  hallucinations,  and  both  were  very  much 
alike.  They  became  so  violent  in  their  demonstrations  that  ere  long 
both  were  taken  to  the  asylum,  where  I  took  charge  of  them.  They 
were  separated,  the  result  being  that  one  became  rapidly  demented  and 
the  other  became  a  quiet  worker,  with  fixed  persecutory  ideas  and 
auditory  hallucinations. 

Another  pair  of  sisters,  colored,  between  forty  and  fifty  years  of 
age,  were  similarly  affected.  For  ten  years  one  sister  had  been  a  para- 
noiac, with  delusions  of  persecution  by  means  of  electricity,  which 
was  at  all  times,  night  and  day,  hurled  through  her  body  by  a  vast 
organization  of  conspirators.  She  had  hallucinations  of  hearing.  The 
sisters  had  not  lived  together  until  within  six  months  of  my  seeing  them, 
the  sane  sister  having  recently  become  a  widow.  The  sane  sister  grad- 
ually adopted  the  delusions  of  the  insane  one,  and  probably  the  hallu- 
cinations. She  believed  her  sister  to  be  persecuted  by  an  organized  band 
of  conspirators  with  electrical  appliances. 

A  third  case  was  that  of  a  husband  and  wife,  who  both  became 
typical  cases  of  melancholia,  with,  of  course,  similar  delusions,  one 
shortly  after  the  other.  Such  a  case  as  this  might  be  called  a  coinci- 
dence, and  not  an  imposed  insanity.  Probably  grief  over  the  insanity 
of  the  husband  was  one  factor  in  developing  that  of  the  wi{e,  but 
unconscious  emotional  imitation  between  two  persons  united  by  special 
bonds  of  sympathy  was  undoubtedly  another  element. 

A  fourth  example  I  detailed  fully  some  years  ago  in  the  "  Alienist 
and  Neurologist"  ("  Paranoia  in  Two  Sisters,"  January,  1890)  : 

C.  K.  and  H.  K.  were  respectively  thirty-six  and  forty-two  years  of 
age,  teachers  of  music  and  singers  by  occupation,  of  German  parentage, 
and  had  both  been  insane  for  some  ten  years.  Their  mother  was  a  case 
of  paranoia,  with  fixed  delusions  of  an  exalted  religious  nature.  She 
believed  herself  to  be  the  mother  of  God.  She  was  never  in  an 
asylum,  but  lived  at  home  until  her  death.  AVhile  insane  she  gave 
birth  to  the  younger  of  the  two  sisters,  C.  K. 

One  of  them  wrote  for  me  an  autobiographical  sketch,  and  the  other 
some  twenty-five  letters,  upon  which  the  following  facts  in  their  identi- 
cal clinical  history  are  based  : 

The  instigators  of  the  conspiracy  against  them  are  chiefly  their 
uncle,  brother-in-law,  and  sister-in-law,  and  a  brother  has  also  been 
inveigled  into  it.  By  them  are  employed  numerous  detectives,  expert 
chemists,  and  handicraftsmen,  and,  as  they  have  privately  hinted  to  me, 
also  many  lawyers.  Openings  are  made  in  their  rooms  in  spite  of  all 
they  can  do  for  the  insufflation  of  noxious  gases,  smoke,  camphorous, 
chloral,  and  chloroform  vapors ;  and  by  some  unseen  agency  substances 
are  thrown  at  them  which  produce  painful  cutaneous  eruptions.  Their 
food  and  water  and  heating  apparatus  are  tampered  with  for  the  intro- 
duction of  poisons  or  to  produce  serious  illness.  They  hear  the 
mechanics  at  work  upon  the  floors,  walls,  ceiliugs,  and  the  voices  of  the 
detectives  (hallucinations  of  hearing).  Their  food  has  a  peculiar  taste 
(hallucinations   of   taste).      Most   prominent   of    all   are   the   singular 


GENERAL   ETIOLOGY  OF  INSANITY.  725 

odors  of  the  room,  of  fruit  and  flowers  sent  them,  of  the  water  (hallu- 
cuiations  of  smell).  Sometimes  they  are  blaelv  in  the  morning  when 
they  look  in  the  mirror  (illusion  of  sight).  Tliey  are  subject  to  remark- 
able, generally  painful,  sensations  in  their  bodies  (hallucinations  and 
illusions  of  cutaneous  sensibility). 

They  hint  of  imaginary  property  in  Germany,  out  of  which  they 
are  being  defrauded  by  relatives.  For  ten  or  twelve  years  they  have 
been  driven  from  one  place  to  another  in  Brooklyn  and  Xew  York  by 
their  pursuers.  As  yet  they  have  sought  only  escape  and  protection 
from  persecution  ;  they  have  very  rarely  manifested  anger  by  pounding 
the  floor  when  hearing  the  mechanics  at  work  or  by  complaint  to  the 
landladies,  and  have  not  been  brought  to  bay  to  a  condition  in  which 
they  might  turn  upon  the  actual  instigators  of  the  conspiracy  and  do 
them  bodily  harm.  They  have  been  on  the  point  of  a  visit  to  police 
headquarters  to  make  declaration  against  their  enemies. 

From  what  I  can  learn  of  their  history  in  youth  the  two  girls 
differed  from  others  of  their  age  in  a  slight  degree,  some  trifling  eccen- 
tricities and  some  overweening  self-consciousness  constituting  this 
difference.  They  have  always  been  closely  united — living  together, 
sleeping  together,  having  the  same  affinities,  talents,  pleasures,  and  pur- 
suits. The  development  of  suspicions  and  delusions  of  persecution  had 
been  so  gradual  that  it  did  not  become  evident  to  others  that  they  were 
actually  insane  until  a  comparatively  recent  period.  When  I  first  saw 
them  in  my  office,  they  came  heavily  veiled,  and,  upon  removing  their 
veils,  their  faces  were  patched  all  over  with  small  square  pieces  of 
cloth,  covering  sores.  These  were  only  an  ordinary  acne,  made  much 
worse  by  picking,  by  wearing  wet  cloths  on  their  faces  all  night  for  the 
purpose  of  preventing  poisonous  vapors  from  entering  their  lungs,  and 
by  the  removal  of  the  strongly  adhering  pieces  of  linen  from  the  bleed- 
ing surfaces.  They  healed  up  rapidly  when  I  had  prevailed  upon  them 
to  make  use  of  ung.  zinci  ox.  freely.  The  face  of  the  younger  is  par- 
ticularly characteristic  of  a  degenerate  type,  one  of  its  features  being  a 
disagreeable  prognathism. 

Some  of  the  skull  diameters  were  pathological  in  character.  One 
of  the  sisters  died  in  con\Tilsions  from  unknown  cause,  which  the  other 
sister  still  attributes  to  poison.  The  living  sister  still  moves  about  from 
one  part  of  the  city  to  another,  cherishing  the  paranoiac  delusions,  but 
supporting  herself  in  part  by  teaching  music. 


726  MENTAL  DISEASES. 


CHAPTER  III. 
GENERAL  SYMPTOMATOLOGY  OF  INSANITY. 

Every  psychic  phenomenon  is  accompanied  by  a  material  process 
in  the  cortex  of  the  brain.  There  is  no  insanity  without  disease  of  the 
cortex.  The  material  disorder  of  the  cortex  is  diflPuse  and  partly 
organic,  but  mostly  functional  in  character.  We  term  it  functional,  for 
thus  far  our  pathologico-anatomical  and  clinical  studies  have  failed  to 
reveal  any  definite  material  basis  for  the  majority  of  psychoses. 

The  progress  made  of  late  years  in  the  study  of  physiological  psy- 
chology has  illuminated  many  obscure  features  of  morbid  psychology, 
and  has  put  us  in  a  position  to  better  examine  and  classify  the  symp- 
toms of  insanity. 

There  are  material  processes  in  the  central  nervous  system  unaccom- 
panied by  any  parallel  psychic  process.  The  reflexes  and  automatic 
acts  are  examples.  In  these  phenomena  we  observe  a  stimulus,  a  sen- 
sation, a  movement.  Movement  paralleled  by  a  psychic  process  be- 
comes action.  We  sometimes  speak  of  conscious  voluntary  action. 
Action  differs  from  simple  movement  in  being  accompanied  by  intercur- 
rent images — memory-pictures  of  former  stimuli.  A  peripheral  stimulus 
excites  a  cortical  center,  and  is  not  carried  at  once  to  the  motor  region, 
but  travels  first  by  association  fibers  to  the  area  in  which  are  stored  up 
residua  of  former  similar  stimulations,  and  later  to  the  motor  region. 
These  residua  of  memory-pictures  or  ideas  may  be  complex,  constitute 
a  series,  have  many  associations,  and  hence  we  designate  them  as  an 
idea-association.  Action,  therefore,  consists  of  the  series  :  stimulus, 
sensation,  idea-association,  movement.  The  various  ideas  thus  excited 
tend  to  diiferent  motors-expressions,  so  that  the  resulting  movement  or 
action  will  depend  directly  upon  the  strength  of  ideas.  The  stronger 
ones  conquer.  Ziehen,  whose  clear  explication  of  the  mental  problems 
of  psychiatry  the  writer  closely  follows,  ^  has  well  described  idea-asso- 
ciation as  the  play  or  battle  of  motives.  He  gives  the  following  exam- 
ple of  the  physical  and  psychic  processes  just  described  : 

I  see  a  rose  in  a  strange  garden  (stimulus  and  sensation).  A  long 
series  of  ideas  is  aroused  by  the  stimulus  and  the  visual  sensation  of 
the  flower  (idea-association).  For  instance,  the  memory  of  the  rose's 
fragrance  comes  to  mind,  then  I  think  how  well  it  would  look  in  my 
room,  that  it  is  the  property  of  another,  that  plucking  it  would  be 
punishable,  and  so  on.  Only  after  the  whole  series  of  presentations  has 
passed  before  the  mind  does  action  follow,  and  whether  I  pluck  the 
flower  or  go  my  way  without  it  will  depend  upon  the  strength  and 
intensity  of  the  conquering  idea. 

Every  psychic  process  must  be  regarded  upon  the  basis  of  such  a 

1  "  PsycMatrie, "  Th.  Ziehen,  Berlin,  1894. 


GENERAL  SYMPTOMATOLOGY  OF  IN8ANLTY.  727 

scheme,  and  as  accompanied  by  its  material  parallel  (progress  from  the 
sensory  cells  to  the  idea-cells,  and  from  these  to  motor-cells  by  means 
of  association-fibers). 

Sometimes  the  idea  of  movement  (memories  of  former  sensations  of 
movement)  comes  before  the  movement  in  the  series  just  described,  but 
generally  the  movement  is  perceived  after  it  has  taken  place  by  means 
of  the  sensation  of  the  movement. 

There  are  really  but  two  psychological  elements — viz.,  sensation  and 
idea.  The  only  process  connected  with  these  elements  is  the  idea- 
association.  Their  product  is  action.  The  so-called  mental  powers  of 
old-time  psychology  do  not  exist.  The  assumption  of  a  special  power 
of  will  dominating  the  idea-association  and  voluntarily  determining  this 
or  that  movement  is  particularly  superfluous  and  misleading.  The 
assumption  of  a  special  power  of  apperception  which  turns  its  "  atten- 
tion "  voluntarily  upon  this  or  that  idea  or  sensation  to  determine  the 
course  of  the  idea-association  is  equally  superfluous. 

The  presentations  or  ideas  rather  follow  one  another  according  to  laws 
without  intervention  of  any  especial  voluntary  power  of  the  mind,  and 
the  final  movement  or  action  is  the  necessary  result  of  association  of 
these  presentations  or  ideas.  Finally,  there  exists  no  particular  faculty 
of  feeling,  for  exact  investigation  demonstrates  that  our  feelings  of 
what  is  agreeable  and  what  is  distasteful,  of  pleasure  and  pain,  appear 
never  in  an  isolated  state,  but  always  combined  with  sensation  and  idea 
as  attributes  or  properties.  ^ 

Following  Ziehen  in  these  particulars,  we  shall  study  pathological 
psychological  processes  on  the  basis  of  the  scheme  just  described,  and 
in  each  case  investigate,  first,  disorders  of  sensation  ;  then,  disorders  of 
the  memory-pictures,  presentations,  or  ideas ;  then,  again,  disturbances 
of  the  idea-association  ;  and,  finally,  the  influence  of  these  disturbances 
upon  the  actions  or  conduct  of  the  patient. 


DISORDERS  OF  SENSATION. 

Sensation  is  the  first  element  in  the  psychic  process.  It  is  deter- 
mined by  some  external  stimulus  affecting  any  sensory  nerve.  Every 
sensation  has  four  important  attributes — viz.,  quality,  intensity,  tone  (the 
accompanying  feeling  of  pleasure  or  pain),  and  space-projection.  We 
are  not  especially  concerned  with  the  last  in  morbid  psychology. 

Qualitative  Disorders  of  Sensation. — The  two  important  classes 
of  qualitative  disorders  of  sensation  are  hallucinations  (in  which  we  have 
sensation  without  external  stimulus)  and  illusions  (in  which  we  have  the 
external  stimulus,  but  a  transformed  or  perverted  sensation).  An  ex- 
ternal stimulus  to  a  peripheral  nerve  is  carried  to  the  cortex,  where  it 
acts  as  a  secondary  stimulus  in  exciting  sensation. 

Hallucinations. — A  hallucination  is  a  sensory  impression  without 
external  stimulus.     It  is  often  also  defined  as  a  perception  without  an 

^  "  Leitfaden  der  physiologisclaeu  Psychologie, "  von  Th.  Ziehen,  Jena,  1893. 


728  MENTAL  DISEASES. 

object.     The  patient  hears  voices  where  all  is  silent,  sees  forms  and 
figures  in  empty  space. 

Hallucinations  of  sight  are  very  common,  and  vary  from  the  simplest 
sparks,  lights,  shimmers,  flames,  spots,  threads,  clouds,  and  shadows  to 
the  most  complicated  groups  of  persons  and  landscapes  with  perfect 
details.  Sometimes  they  are  colorless,  like  silhouettes  ;  sometimes  radi- 
ant and  fantastic  with  color.  Sometimes  they  are  flat,  like  pictures  ; 
sometimes  plastic.  Ordinarily,  the  forms  and  objects  observed  are  of 
natural  size,  but  occasionally  they  are  gigantic  or  diminutive.  They 
may  appear  close  at  hand  or  far  away.  They  may  be  quiet  or  full  of 
movement,  like  the  zooscopic  hallucinations  of  alcoholism.  Karely, 
real  objects  are  doubled  or  multiplied  (hallucinatory  diplopia  and  poly- 
opia). Real  objects  are  sometimes  concealed  by  the  hallucinations, 
sometimes  merely  diaphanously  veiled.  Hallucinations  may  fill  the 
whole  field  of  vision  or  appear  in  homonymous  half-fields,  as  in  the 
hemiopic  hallucinations  described  by  the  writer  in  cases  of  insanity  and 
of  homonymous  hemianopsia. 

Hallucinations  of  hearing  are  also  extremely  frequent,  and  vary 
from  simple  sounds,  tinnitus  aurium,  rushing,  roaring,  whispering, 
tinkling,  to  complicated  music  and  words  and  sentences.  These  last 
may  be  in  natural  tone  or  deep-voiced,  whispered  or  loud ;  may  be  the 
voice  of  one  or  many  persons  ;  may  be  pronounced  in  various  languages  ; 
may  be  single  words  or  long  orations  ;  may  seem  near  at  hand  or  far 
removed  ;  and  may  be  heard  in  one  ear,  though  usually  in  both.  Not 
infrequently  the  voice  seems  to  the  patient  so  near  that  it  appears  to  be 
in  his  head  or  body.  ' 

Hallucinations  of  common  cutaneous  sensibility  may  appear  any- 
where in  the  skin  or  in  mucous  membranes  in  the  form  of  electric 
shocks,  pricking,  tingling,  blows,  caresses,  sensations  of  heat  or  cold, 
indignities  to  the  sexual  organs  (feeling  of  cohabitation),  etc. 

Hallucinations  of  smell  are  very  common.  The  patients  perceive 
odors  of  chloroform,  sulphur,  noxious  gases,  smoke,  filth,  or,  on  the 
other  hand,  the  smell  of  perfumes  and  flowers. 

Hallucinations  of  taste  are  so  generally  combined  with  those  of 
smell,  because  of  the  close  physiological  relation  of  the  two  senses,  that 
true  hallucinations  of  the  primary  elements  of  taste  (salt,  sweet,  bitter, 
and  sour)  are  uncommonly  rare.  A  hallucination  of  a  bitter  taste  is 
the  most  frequent.  On  the  other  hand,  the  combined  hallucination  of 
taste  and  smell  (as  of  blood,  filth,  etc.)  is  rather  common. 

Hallucinations  of  organic  sensation  are  not  rare.  The  patients  com- 
plain of  peculiar  or  extraordinary  feelings  in  various  organs,  such  as 
malposition,  gnawing,  cutting,  pain,  etc. 

Hallucinations  of  active  or  passive  movement  of  the  body  or  its 
parts  depend  probably  chiefly  upon  disorders  of  joint  sensibility.  The 
patients  feel  themselves  lifted  in  the  air,  floating,  the  limbs  moved 
actively,  the  head  turned  to  one  side  ;  or,  the  sensation  of  movement  of 
the  muscles  required  for  speech  may  give  rise  to  the  hallucination  of" 
having  spoken  a  word  or  sentence. 


GENERAL  SYMPTOMATOLOGY  OF  INSANITY.  'i'29 

Various  lialliK-inations  are  often  associated  in  such  a  manner  as  to 
render  the  hallucinated  objects  still  more  natural  and  deceptive,  though 
more  frequently  they  are  not  thus  commingled.  Thus,  visionary 
figures  may  speak  or  be  dumb,  and  the  fancied  voices  may  come  from 
visually  projected  or  from  unseen  persons.  Sometimes  vision,  hearing, 
and  cutaneous  sensation  may  be  combined  to  give  reality  to  the  object. 
Combinations  of  others  are  also  met  with,  and,  indeed,  these  mixed 
hallucinations  are  common  and  multiform. 

As  regards  the  development  of  hallucinations,  some  are  doubtless 
peripheral,  but  the  majority  are  central  in  their  origin.  Disorders  of 
the  eve,  ear,  nasal  cavity,  mouth,  mucous  membranes,  skin,  and  viscera 
may  give  rise  to  hallucinations,  though  they  are  more  commonly  the 
cause  of  illusions.  Hallucinations  are  never  new  creations,  but  are  made 
up  of  memory-pictures  stored  up  in  the  cortex  ;  these  may,  however, 
make  their  appearance  in  new  combinations.  The  congenitally  blind 
never  have  visual  hallucinations ;  the  congenitally  deaf  never  auditory 
hallucinations,  though  they  are  noted  in  acquired  blindness  and  deaf- 
ness. 

Hallucinations  are  usually  of  two  kinds — those  which  have  to  do 
with  the  ideas  presented  in  the  mind  at  the  time  of  their  manifestations, 
and  those  which  are  concerned  with  latent  memory-pictures.  The 
former  are  more  common,  but  both  may  be  observed  in  the  same 
patient.  The  first  kind  are  those  which  the  patient  describes  as 
visions  which  picture  his  very  ideas,  and  voices  which  read  off  his 
thoughts  as  fast  as  they  can  come  into  his  mind — indeed,  often  appar- 
ently before  he  thinks  them.  The  second  class  of  hallucinations  often 
astounds  the  patient  by  association  with  things  long  past  and  quite 
forgotten. 

AVe  are  taught  by  physiological  psychology  that  a  stimulus  to  the 
eye  arouses  a  sensation  in  the  occipital  lobe,  to  the  ear  a  sensation  in  the 
temporal  lobe,  and  so  on,  the  sensation  further  exciting  an  image  which 
remains  as  a  memory-impression.  All  normal  sensations,  then,  depend 
u]jon  the  series  stimulus,  sensation,  memory-picture,  or  idea.  Now, 
hallucinations  are  always  cortical,  as  regards  localization,  and  depend 
upon  a  reversal  of  the  normal  course  just  described,  and  without  the 
stimulus.  The  memory-image  is  excited  and  then  excites  the  sensation. 
A  certain  irritability  of  these  centers  will  be  induced,  undoubtedly, 
by  morbid  processes  in  the  peripheral  nerves  or  their  terminations, 
such  as  entoptic  or  entotic  processes,  which  will  render  them  all  the 
more  excitable,  since  external  stimulus  is  not  then  altogether  wanting. 
Finding  such, — and  we  should  always  investigate  carefully  for  a  periph- 
eral physical  ba«is, — the  dividing-line  between  hallucinations  and  illu- 
sions becomes  less  distinct.  Naturally,  the  normal  mind  recognizes  the 
real  nature  of  muscse  volitantes,  tinnitus  aurium,  neuralgic  pains,  etc., 
and  it  is  only  the  abnormal  mind  which  employs  them  as  material  for 
illusions  and  hallucinations. 

In  the  examination  of  a  patient  we  must  determine  the  presence  of 
hallucinations  and  the  effect  of  their  presence  on  idea-association.     One 


730  MENTAL  DISEASES. 

must  not  mistake  actual  occurrences  described  by  the  patient,  nor  the 
events  of  dreams  confused  by  him  with  events  of  waking,  nor  ordinary 
iUusions  for  hallucinations.  There  is  danger,  too,  of  overlooking  their 
presence.  Patients  conceal  them,  conscious  that  the  hallucinations  are 
morbid,  or  knowing  that  they  will  be  looked  upon  as  such,  but  will 
often  write  about  them  or  tell  of  them  to  other  patients  if  opportunity 
be  given.  Very  often  the  physician  is  enabled  to  recognize  their  exist- 
ence from  the  expression  and  conduct  of  the  patient. 

As  regards  the  influence  of  hallucinations  upon  the  course  of  idea- 
association,  the  most  important  question  is  whether  they  are  regarded 
by  the  patient  as  real  sensations  or  not.  He  treats  them  as  actual 
phenomena,  as  if  they  were  normal  sensations,  or  he  distinguishes  them 
from  his  ordinary  sensations  as  peculiar,  novel,  and  possibly  inspired  by 
supernatural  agencies  ;  or  he  is  really  conscious  of  their  morbidity,  but 
may  believe  them  to  be  induced  by  enemies  by  means  of  poison.  If  the 
hallucinations  are  faint  and  transitory,  the  patient  may  not  be  much  in- 
fluenced by  them  ;  if  they  are  marked  and  persistent  for  a  long  period, 
he  ultimately  loses  his  critical  faculty  and  comes  to  believe  in  their 
reality.  Such  being  the  case,  his  thought  and  conduct  are  bound  to  be 
influenced  by  them,  and  more  powerfully  influenced  than  by  normal 
sensations,  or  by  any  reasonable  consideration  or  argument.  Hallucina- 
tions either  inhibit  (hallucinatory  stupor)  or  retard  (hallucinatory  con- 
fusion) the  idea-association ;  or  they  induce  direct  intrinsic  delusions  (as 
when  a  voice  cries  "  Thou  art  God,"  and  the  patient  immediately  be- 
lieves himself  to  be  God).  The  actions  and  conduct  of  a  patient  are 
very  much  influenced,  and  in  multiform  ways,  by  hallucinations.  He 
has  the  expression  of  listening,  or  stares  apparently  at  nothing.  He 
closes  his  ears,  covers  his  eyes  or  head,  closes  up  cracks  and  openings, 
or  listens  at  the  window  or  keyholes.  He  refuses  or  spits  out  his  food. 
He  holds  his  nose,  or  suddenly  closes  the  window  to  prevent  the  entrance 
of  noxious  gases.  He  turns  his  head,  runs,  shouts,  lifts  his  arm  quickly, 
or  takes  peculiar  attitudes,  acting  upon  a  hallucination  of  muscular 
sense  (imperative  movements,  imperative  speech,  imperative  attitudes). 
The  imperative  attitudes  may  be  very  persistent  and  long-continued,  and 
are  then  called  catatonic.  Hallucinations  often  lead  to  imperative  acts 
which  may  be  of  a  violent  nature.  If  hallucinations  are  innumerable, 
very  changeable,  and  intense,  the  patient  is  affected  by  so-called  hallu- 
cinatory agitation. 

Hallucinations  are  so  extremely  rare  under  normal  conditions  that 
they  are  to  be  considered  as  almost  always  pathological.  Illusions  are 
rather  common  in  the  normal  mind.  True  hallucinations  may  occur  in 
apparently  normal  individuals,  but  examination  will  show  that  such 
persons  are  neurotic  by  heredity,  and  that  some  stress  of  mind  or  body 
has  induced  this  psychopathic  phenomenon.  This  is  particularly  true 
in  childhood. 

Outside  of  the  psychoses,  hallucinations  are  met  with  in  toxic  states, 
fevers,  cachectic  conditions,  sun-stroke,  and  some  of  the  neuroses  (epi- 
lepsy, chorea,  hysteria).  A  hallucination  of  any  sense  may  be- the  aura 
of  an  epileptic  attack  ;   sometimes,  when  visual,  it  may  be  hemiopic. 


GENERAL  SYMPTOMATOLOGY  OF  INSANITY.  731 

Hallucinations  are  the  chief  symptom  of  one  form  of  paranoia. 
Other  psychoses,  such  as  mania  and  melancholia,  manifest  them  only 
exceptionally  ;  while  still  others,  like  senile  and  paretic  dementia,  pre- 
sent hallucinations,  it  is  true,  but  not  in  such  prominence  as  to  make 
them  a  characteristic  symptom.  Visual  hallucinations  are  more  com- 
mon in  acute  than  in  chronic  psychoses,  and  they  are  seldom  indepen- 
dent of  hallucinations  of  feeling  and  hearing.  Auditory  hallucinations, 
on  the  other  hand,  are  more  characteristic  of  chronic  types  of  mental 
disorder,  and  are  often  observed  alone. 

The  close  union  of  the  auditory  center  with  the  motor  speech  center 
gives  a  peculiar  interest  to  hallucinations  of  hearing.  From  infancy 
man  is  trained  to  think  to  a  great  extent  in  word-images  or  speech- 
images,  and  thinking  is,  therefore,  nearly  always  associated  with  some 
stimulation  of  the  speech-muscle  centers  in  the  brain.  Therefore,  hal- 
lucinatory irritation  in  the  auditory  area  of  the  brain  causes  synchronous 
irradiation  to  the  motor  speech  center,  and  words  and  sentences  are 
heard  by  the  hallucinant  as  if  projected  into  the  external  world,  or  into 
some  part  of  the  patient's  body  (head,  throat,  chest,  stomach,  or  even 
extremities).  The  stimulation  of  the  speech  muscles,  however  feeble, 
may  be  sufficiently  strong  to  induce  recurrent  sensations  of  movement 
in  them,  which  leads  the  patient  to  imagine  that  his  thoughts  are  being 
read  oif  internally  by  the  voice,  and  sometimes  repeated  apparently 
before  the  thought  has  fully  developed  in  his  brain. 

Illusions. — An  illusion  is  a  false  perception.  There  is  a  stimulus 
but  a  perverted  sensation,  a  wrong  interpretation.  The  sensation 
corresponds  only  in  part  to  the  stimulus.  A  patient  hears  the  rain 
falling,  but  perceives  it  as  music ;  he  sees  the  bedpost,  but  imagines  it 
a  ghost. 

Visual  illusions  exhibit  a  transformation  of  form,  or  color,  or  both. 
This  is  often  favored  by  indistinctness  of  outline,  as  when  it  is  half  dark 
or  there  is  a  shimmering,  flickering  light.  But  often  clear  outlines  are 
transformed.  The  patient  may  see  the  familiar  faces  about  him  changed 
into  those  of  strangers,  transformed  by  grimaces,  or  deathly  pale.  A 
sharp  distinction  between  illusory  transformation  and  actual  hallucina- 
tion is  often  difficult  to  draw.  It  is  peculiar  to  illusions  that  they  not 
infrequently  present  objects  as  distorted  and  diminished  or  increased  in 
size.  This  is  especially  true  among  epileptics.  When  this  is  noted 
with  all  objects,  it  often  depends  upon  entoptic  disorders.  Thus,  meta- 
morphopsia  may  arise  from  astigmatism  and  retinal  disease,  micropsia 
from  paresis  of  accommodation,  and  macropsia  from  spasm  of  accommo- 
dation. When  this  is  not  the  cause,  perverted  association  of  the  sensa- 
tion, with  disordered  muscular  sense,  may  play  a  role.  Sometimes, 
though  rarely,  the  illusion  may  consist  of  a  perversion  of  color  analogous, 
for  instance,  to  the  yellow  appearance  of  objects  in  santoijin-poisoning 
(due  to  violet  blindness  induced  by  the  poison)  or  to  red  vision  (ery- 
thropsia  induced  by  fatigue  of  the  retina  for  the  short-waved  rays  of  the 
violet  side  of  the  spectrum). 

Illusions  of  hearing  consist  mostly  of  the  construction  of  words  out 
of  inarticulate  sounds,  or  of  the    misinterpretation    of  the   words   or 


732  MENTAL   DISEASES. 

sentences  spoken  in  the  patient's  hearing.  He  may  transform  them  into 
mocking,  indecent,  derogatory,  or  flattering  words. 

lUusions  of  common  sensibility  are,  perhaps,  more  important  in 
insanity  than  hallucinations  of  this  sense.  But  they  are  difficult  to 
study  and  establish.  It  is  probable  that  the  sandy,  earthy  taste  of  food 
often  complained  of  by  patients  is  more  an  illusion  of  touch  than  of  taste. 

Illusions  of  smell  and  taste  are,  in  the  main,  unpleasant  in  character 
and  are  more  common  than  hallucinations  of  these  senses. 

Illusions  of  organic  sensation  are  frequently  noted,  and  consist  of  such 
sensory  metamorphoses,  for  instance,  as  the  mistaking  of  intestinal 
motions  for  pregnancy,  and  the  feeling  of  diminution  or  increase  in  size 
of  various  organs  (particularly  noticeable  in  epilepsy  and  paresis). 

Illusions  of  muscular  sense  or  of  movement  are  rare. 

Illusions,  like  hallucinations,  may  form  their  material  from  the 
concepts  at  the  moment  in  consciousness,  or  from  latent  memory -pictures. 

The  theory  of  the  cause  of  illusions  is  analogous  to  that  of  hallucina- 
tions. They  arise  from  a  pathological  recurrent  influence  of  the  excited 
memory-picture  cells  upon  the  sensory  cells.  The  difference  lies  in  the 
association,  also,  of  an  actual  external  stimulus  which  undergoes  trans- 
formation. 

Illusions  are  much  more  common  than  hallucinations,  and  are  not 
seldom  met  with  in  normal  jjersons.  Often  they  are  difficult  to  dis- 
tinguish from  one  another.  Sometimes  it  is  impossible  to  differentiate 
true  illusions  from  so-called  illusionary  judgments,  in  which  we  are 
concerned  not  so  much  with  a  transformation  of  sensation,  as  with  an 
erroneous  judgment  of  the  character  of  a  normal  sensation. 

Illusions  are  noted  in  all  forms  of  psychoses,  especially  in  acute 
forms.  They  are  particularly  noteworthy  in  the  hallucinatory  form  of 
paranoia. 

Disorders  of  Intensity  of  Sensation. — These  consist  of  hypesthe- 
sias,  anesthesias,  and  hyperesthesias.  Hypesthesias  and  anesthesias  are 
observed  in  various  psychoses  which  are  complicated  by  such  disorders 
as  hysteria,  chorea,  multiple  neuritis,  tabes,  focal  cerebral  lesions,  etc. 
Hyperesthesia  is  also  encountered  in  complicating  disorders,  such  as  hys- 
teria, tubercular  meningitis,  neurasthenia ;  but  is  also  often  noted  in  the 
prodromal  stages  of  many  acute  psychoses.  It  is  especially  remarkable 
in  the  insanities  of  childhood.  A  valuable  objective  sign  of  hyper- 
esthesia is  exaggeration  of  the  superficial  reflexes. 

Disorders  of  Sensory  Tone. — Agreeable  or  disagreeable  feeling, 
associated  with  sensation,  is  described  as  sensory  tone.  Sensory  tone  may 
be  perverted  in  insanity  so  that,  for  instance,  fragrance  is  perceived  as 
unpleasant,  dissonance  as  pleasant,  and  vice  versa.  One  notes  such  per- 
versions in  the  slight  psychopathic  conditions  of  pregnancy  in  the  foriu 
of  capricious  tastes  and  appetites.  Homosexual  perversion  is  a  form  of 
this  disorder  manifested  in  the  domain  of  sexual  sensation.  Pathologi- 
cal disorders  of  the  intensity  of  sensory  tone  consist  of  hypalgesia  and 
analgesia,  hyperalgesia,  hyphedonia,  and  hyperhedonia. 

The  hypalgesias  are  noted  in  hysteria,  tabes,  congenital  and  acquired 
mental  deficiency,  and  in  severe  hallucinatory  confusion. 


GENERAL  SYMPTOMATOLOGY  OF  INSANITY.  733 

Hyperalgesia  is  observed  under  the  same  circumstances  as  hyper- 
esthesia. It  is  most  often  seen  in  hysterical  and  neurasthenic  insanities, 
and  almost  exceptionally  at  certain  points  (such  as  the  supraorbital, 
infraorbital,  mental,  Valleix,  iliac,  intercostal,  mammary,  vertebral,  and 
cranial  suture  points)  pressure  elicits  pain.  The  pain  of  hunger,  which 
leads  in  many  psychoses  to  pathological  hunger  (bulimia)  belongs  in 
this  category. 

Hyphedonia  is  a  morbid  diminution  of  the  feeling  of  pleasure  in  any 
sensory  perception.  It  is  more  important  in  the  domain  of  sexual  sen- 
sations than  in  others,  where  it  may  reach  the  degree  of  anhedonia. 
Sexual  anhedonia  is  not  uncommonly  developed  on  the  basis  of  a  seri- 
ous hereditary  degeneracy,  and  is  frequent,  too,  in  organic  disease  of 
the  central  nervous  system  (tabes  and  paresis),  as  well  as  in  toxic  con- 
ditions (alcohol,  cocain,  morphin).  Hyphedonia,  in  connection  with 
hunger  sensations,  may  reach  the  state  of  complete  psychic  anorexia  in 
some  insanities. 

Hyperhedonia  is  a  morbid  increase  of  positive  sensory  tone  (agree- 
ability  of  sensation),  and  is  noted  most  often  in  relation  to  sexual 
sensations. 

Disorders  of  Memory-pictures  or  Ideas. — Every  stimulus  in 
arousing  a  sensation  in  the  cerebral  cortex  leaves  some  material  vestige 
or  impression,  which  remains  as  a  latent  memory-image  or  picture, 
latent  presentation,  or  idea.  Countless  numbers  of  memory-pictures  left 
by  innumerable  sensations  of  all  kinds  are  stored  away  as  a  material 
deposit  in  the  brain-cortex.  These  are  rearoused  either  by  the  same  or 
a  similar  stimulus,  or  excited  through  the  stimulus  of  some  idea- 
association.  Only  a  few  of  the  millions  of  memory-pictures  are 
awakened  to  life  at  any  one  moment ;  all  of  the  others  remain  latent. 
The  general  concept  of  any  particular  object  is  made  up  of  the  associa- 
tion of  many  centers  in  the  brain,  some  of  which  are  far  apart,  such  as 
the  smell,  feel,  taste,  color,  sound,  and  name  of  the  object.  The  rela- 
tion of  this  object  to  others  of  its  kind  is  present  in  other  associations, 
and  these  again  in  others,  so  that  the  material  basis  of  an  idea  must  be 
a  perfect  network  of  association  fibers ;  and  all  of  this  labyrinth  is  con- 
nected with  the  complex  series  of  language-centers,  but  particularly 
with  the  motor  and  auditory  speech-centers,  which  are  trained  up  from 
earliest  infancy  to  associate  the  sjjoken  word  with  the  concrete  concep- 
tion. A  word,  therefore,  expresses,  like  an  algebraic  x,  y,  or  z,  some 
very  intricate  and  complicated  formula.  Take  words  like  "home," 
"  right,"  "  wrong,"  and  so  on,  and  think  what  a  countless  number  of 
associated  memory-pictures  each  one  must  represent !  Words  are 
simply  convenient^ abbreviations  which  render  more  easy  the  use  of  con- 
cepts in  idea-associations. 

We  distinguish  in  every  idea  four  cardinal  properties  :  (1)  The  con- 
tents or  meaning ;  (2)  distinctness ;  (3)  associated  affects ;  (4)  energy 
or  intensity. 

The  pathological  disturbances  of  ideas  may  be  studied  under  the 
headings  of  disorders  of  their  evolution,  durability,  concomitant  aiFects 
and  associations. 


734  MENTAL   DISEASES. 

Defective  Evolution  of  Ideas. — The  number  of  concepts  stored  up 
in  the  brain  varies  enormously  under  normal  conditions  with  individuals 
and  races.  In  morbid  psychology  we  find  the  number  of  ideas  extremely 
small  among  congenital  defectives,  such  as  the  idiot,  the  imbecile,  and 
the  feeble-minded.  The  idiot  may  preserve  rudimentary  memory- 
pictures  of  the  simplest  things,  such  as  food  and  eating,  light,  dark- 
ness, clothing,  but  without  speech  associations  ;  he  will  have  none  of 
other  persons  or  other  objects  about  him.  In  the  imbecile  the  concepts 
are  more  numerous  and  may  be  known  by  name  ;  he  recognizes  persons 
and  objects,  distinguishes  simple  colors  with  difficulty,  may  have 
number  concepts  as  high  as  ten ;  he  has  a  few  concrete  ideas,  but,  as  a 
rule,  no  abstract  ideas.  The  feeble-minded  has  a  larger  number  of 
memory-pictures,  may  have  abstract  ideas,  recognizes  the  significance  of 
likeness  and  similarity,  and  may  use  the  words  God,  right,  wrong,  etc., 
but  in  reality  be  unable  to  tell  the  meaning  of  such  complex,  abstract 
conceptions.  It  is  necessary,  therefore,  to  avoid  concluding  that  the 
idea  is  present  because  the  word  is  spoken  by  such  a  patient,  for  it  is 
particularly  characteristic  of  the  congenitally  feeble-minded  to  be  apt 
with  words  while  deficient  in  grasp  of  their  meaning. 

Disorders  in  Durability  of  Memory-pictures. — The  forgetting  of 
a  memory-picture,  when  the  stimulus  and  sensation  producing  it  are  not 
repeated,  may  be  considered  to  be  due  to  its  gradual  erasure  by  the  in- 
fluence of  the  nutritive  processes  which  affect  the  cortical  ganglion-cells 
equally  with  all  the  elements  and  tissues  of  the  body.  This  physio- 
logical destruction  of  the  memory-picture  is  always  very  slow,  but  by 
pathological  processes  may  be  rendered  enormously  rapid.  The  de- 
struction may  be  diffuse  or  limited  to  one  sensory  sphere  (for  example, 
apraxia,  where  the  sensory  ideas  of  objects  are  lost,  though  the  sensory 
apparatus  may  be  intact ;  mind-blindness,  word-blindness,  mind-deaf- 
ness, word-deafness,  etc.).  But  these  limited  defects  of  memory-pictures 
are  due  to  focal  lesions  in  the  brain,  and  do  not  concern  the  alienist  so  much 
as  the  diffiise  destruction  of  ideas,  although  it  is  true  that  the  latter  may 
sometimes  be  a  sequel  to  a  circumscribed  lesion,  and,  on  the  other  hand, 
that  the  diff'use  disorder  may,  as  in  general  paralysis,  sometimes  affect 
one  region  more  than  another.  A  loss  of  concrete  ideas,  such  as  general 
concepts  of  relationship,  etc.,  which  are  represented  by  a  wide-spread 
association  network  in  the  whole  cortex,  can  only  be  caused  by  a  diffuse, 
far-reaching  disturbance.  We  see  examples  of  such  loss  in  the  acquired 
dementias  of  paresis,  epilepsy,  and  senility,  dementias  secondary  to 
acute  psychoses,  and  dementias  due  to  toxic  agents.  It  is  natural  that 
the  latest  memory  acquisitions  should  be  lost  first,  and  the  older  mem- 
ories successively  later,  in  direct  proportions  to  their  age,  according  to 
a  certain  "  law  of  regression,"  as  Ribot  terms  it.  This  is  to  be  ex- 
plained by  the  want  of  permanence  and  stability  in  the  newest  arrange- 
ment or  concatenation  of  protoplasmic  molecules  and  ganglion-cells. 
The  older  impressions  have  become  more  fixed  and  durable. 

Since  an  experience  leaves  behind  not  alone  a  single  memory-picture, 
but  a  whole  series  arranged  in  chronological  order,  we  may,  as  in  am- 
nesias, find  pathological  states  in  which  there  are  losses  of  such  series 


GENERAL  SYMPTOMATOLOGY  OF  INSANITY.  735 

of  ideas  during  a  definite  period  of  time.  The  so-called  subconscious 
or  unconscious  states  are  examples  of  this  phenomenon.  They  are 
observed  in  epilepsy,  intoxications,  hysteria,  narcolepsy,  hypnotism, 
somnambulism,  injuries  to  the  head,  and  in  transitory  insanity. 

Affective  Disorders. — Pleasurable  or  disagreeable  feelings  accom- 
pany ideas,  just  as  they  do  common  sensations  ;  so  that  there  is  an  intel- 
lectual aifective  tone  analogous  to  sensory  tone.  If  two  ideas  be  pre- 
sented simultaneously,  and  if  one  of  these  have  a  stronger  emotional 
quality  than  the  other,  the  tone  of  this  will  be  irradiated  to  the  other. 
Ziehen, in  describing  irradiation, gives  the  following  example:  "If  I  have 
met  with  an  accident  in  any  place,  afterward  not  only  is  the  memory  of 
the  injury  accompanied  by  an  unpleasant  feeling,  but  the  memory  of 
the  place  is  likewise  mingled  with  a  disagreeable  affect.  Furthermore, 
when  I  again  see  the  spot  where  the  accident  occurred,  I  may  feel  again 
the  sensation  of  the  injury,  accompanied  by  its  unpleasant  sensory  tone." 
Here  the  memory-picture  arouses  the  sensory  tone  of  the  sensation  ex- 
perienced. This  is  termed  reflected  tone.  The  most  important  conse- 
quence of  the  laws  of  emotional  irradiation  and  reflection  is  that  if  in  a 
certain  period  of  time  one  or  several  sensations  and  ideas  have  a  strong 
and  similar  emotional  tone,  all  other  sensations  and  ideas  presented  to 
the  mind  during  the  same  period  of  time  will  be  colored  by  the  tone  of 
the  former.  Such  irradiation  creates  our  moods,  which  are  hence  the 
abstract  or  summary  of  the  similar  emotional  tones  of  the  ideas  and 
sensations  experienced  within  any  definite  period  of  time. 

Moods  and  emotions  influence  strongly  the  flow  of  our  ideas,  and,  as 
a  consequence,  our  actions.  Depressed  moods  or  affects  inhibit,  while 
exalted  affects  increase  the  flow  of  ideas,  and  likewise  the  resultant 
actions.  Depressed  affects  are  more  durable  and  persistent  than  exalted 
affects.  The  latter  subside  rapidly.  The  more  complicated  ideas,  such 
as  justice,  honor,  law,  family,  patriotism,  etc.,  are  accompanied  by  a 
specific  affect  or  tone  which  we  designate  as  ethical  feeling.  Ethical 
feeling  is  the  result  of  numerous  irradiations,  which  the  single  idea 
acquires  from  all  of  the  ideas  associated  with  it ;  and  the  sum  of  the 
ethical  feelings  of  an  individual  gives  him  his  character  (Ziehen). 

In  morbid  psychology  we  classify  changes  in  the  affects  as  patho- 
logical depression,  exaltation,  irritability,  apathy,  and  mutability. 

Depression. — Depression  is  observed  in  many  forms  of  insanity, 
particularly  as  a  prodrome,  but  is  characteristic  of  the  melancholy  types. 
It  is  a  very  common  prodrome  of  acute  mania,  and  a  long  period  of 
morbid  depression  is  frequently  noted  as  an  antecedent  in  general 
paresis.  It  is  observed  in  neurasthenia,  in  hypochondriasis,  and  not 
seldom  as  an  interlude  in  any  psychosis.  It  is  the  cardinal  symptom 
of  melancholia.  Depression  is  a  normal  consequence  or  accompaniment 
of  sorrowful  or  dreadful  hallucinations  and  ideas,  and  is,  under  such 
conditions,  termed  secondary.  It  is  primary  depression  with  which  we 
are  more  concerned  in  insanity — a  depression  not  at  all  or  but  slightly 
motived  by  such  hallucinations  and  ideas  as  we  have  just  described, 
but  a  mood  which  takes  possession  of  the  mind  of  the  patient  and  gives 
its  own  original  color  to  every  thought  arising  in  his  mind  and  to  every 


736  MENTAL   DISEASES. 

external  object  presented  to  his  consciousness.  Past,  present,  and 
future  are  alike  under  the  shadow  of  this  mood.  When  mild  in  degree, 
the  patient  feels  only  an  inexplicable  sadness — a  certain  restlessness  or 
state  of  worry  ;  but  when  extreme,  this  general  mood  of  sadness  be- 
comes a  condition  of  pathological  anxiety — a  mixed  feeling  of  grief  and 
dread,  often  accompanied  by  a  feeling  of  suifocation  or  pain  about  the 
heart,  and,  therefore,  frequently  designated  as  •''  precordial  anxiety  "  or 
"precordial  fright."  When  primary  depression  is  present,  the  patient 
feels  the  change  in  his  mental  condition,  observes  that  he  no  longer  is 
cheered  by  the  usual  pleasant  events  of  his  daily  life,  that  these  rather 
iutensifv  his  misery.  The  affection  and  sympathy  of  his  friends  and 
family  either  awaken  no  response  in  his  own  breast  when  he  tends  to 
believe  that  he  has  lost  all  natural  feeling,  or  they  may  awaken  sus- 
picion, dislike,  and  distrust.  The  inhibition  of  the  flow  of  thought 
restricts  his  ideas  to  himself  and  to  the  somber  contents  of  his  mind. 
He  is  not  easily  distracted  from  such  contemplation,  and  answers  ques- 
tions, if  at  all,  very  slowly  and  with  great  difficulty.  Nearly  all  cases 
with  morbid  depression  complain  of  disorders  of  visceral  sensibility, 
from  a  slight  sense  of  constriction  at  the  throat  to  precordial  distress, 
from  a  general  feeling  of  illness  and  uneasiness  to  a  feeling  of  extreme 
and  general  restlessness,  Xo  doubt  depression  influences  often  the 
entire  musculature  of  the  body,  so  that  the  patient  wrings  his  hands, 
picks  his  fingers  or  head,  walks  up  and  down,  is  extremely  agitated, 
goes  into  a  condition  of  catalepsy  or  catatonia,  or,  on  the  other  hand, 
remains  absolutely  immobile  and  requires  the  service  of  others  for  every 
movement.  The  muscles  of  the  peripheral  arteries  contract  and  in- 
crease the  frequency  of  the  heart's  action.  The  constriction  of  the 
throat  is  probably  an  actual  contraction  of  the  esophageal  muscles. 
Precordial  anxiety  is  most  likely  due  to  vasomotor  disturbance  in  the 
vessels  of  the  heart.  The  constipation  so  frequent  in  depressed  con- 
ditions depends  doubtless  upon  retardation  of  peristalsis.  Thus  we 
observe  in  one  case  motor  inhibition,  in  another  motor  excitement,  and 
in  some  alternations  between  the  two. 

In  seeking  to  explain  the  mood  of  sadness  and  uneasiness  which  he 
feels,  the  patient  tends  to  develoj)  delusions.  He  invokes  the  first  ideas 
which  would  naturally  come  to  him  under  such  circumstances.  He 
seeks  in  his  past  life  for  some  sin,  the  commission  of  which  may  have 
brought  this  punishment.  He  magnifies  some  trivial  error  in  his  youth 
into  an  unpardonable  sin.  Or  he  comes  to  think  that  poverty  stares 
him  in  the  face,  or  that  he  can  never  recover  from  an  incurable  illness 
which  has  taken  possession  of  him.  Occasionally,  a  persecutory  delusion 
is  evolved  from  a  primary  depression. 

Exaltation. — Exaltation  is  occasionally  noted  as  an  intercurrent 
symptom  in  any  psychosis.  It  sometimes  alternates  with  depression, 
forming  a  constant  cycle,  as  in  circular  insanity,  and  sometimes  it  pre- 
sents itself  during  convalescence  from  melancholia  as  a  reactive  phe- 
nomenon. In  the  majority  of  cases  of  general  paresis  a  period  of 
exaltation  develops.  In  maniacal  states,  however,  it  is  observed  as  a 
cardinal  symptom.     As  with   depression,  we  distinguish  a  secondaiy 


GENFAIAL  SY3IPT03IATOLOGY  OF  INSANITY.  737 

exaltation  consequent  upon  agreeable  hallucinations  and  ideas,  and  a 
primary  or  unniotivcd  exaltation.  In  exalted  moods  the  somesthetic 
sensations  are  pleasurable  and  give  rise  to  feelings  of  perfect  health, 
strength,  and  vitality.  The  stream  of  ideas  is  hastened,  and  as  a 
result  the  patient  becomes,  according  to  the  degree  of  exaltation,  talka- 
tive and  garrulous,  or  exhibits  a  veritable  logorrhea, — a  constant,  rapid 
flow  of  words, — which  may  often  assume  a  rhyming,  singing,  or  orator- 
ical character,  with  marked  incoherence.  The  rapid  stream  of  presen- 
tations is  paralleled  in  the  motor  sphere  by  increased  muscular  activity, 
varying  from  busy  occupation  with  nothing  to  gesticulating,  grimacing, 
and  dancing,  and  to  the  wildest  and  most  violent  motor  excitement. 

Primary  exaltation  frequently  gives  rise  to  delusions  of  a  grandiose 
character,  though  these  are  unstable  and  fleeting,  corresponding  to  the 
rapidity  of  change  in  the  contents  of  consciousness.  But  the  feeling 
of  well-being  and  of  egotism  which  makes  up  the  fundamental  mood 
of  the  exalted  patient  leads  him  to  be  extremely  impatient  of  any 
restraint  of  his  activities  ;  and,  in  consequence  of  this,  the  reactive  feel- 
ing of  aggressive  anger  and  fury  is  easily  aroused,  leading  to  acts  of 
violence  and  destruction. 

Irritability. — Irritability  is  a  condition  which  has  to  do  chiefly  with 
the  aifects  of  anger  and  rage.  While  observed  in  association  wdth 
exaltation,  as  just  noted,  and  among  the  prodromata  of  various  insani- 
ties, it  is  particularly  characteristic  as  a  primary  emotional  state  of 
congenital  and  acquired  mental  weakness,  neurasthenic  insanity,  and  the 
epileptic  psychoses.  In  the  latter  it  not  infrequently  becomes  a  true 
furor  epilepticus.  Irritability  is  occasionally  noted  in  the  convalescence 
from  acute  insanities,  sometimes  conjoined  with  a  peculiar  tearfubiess, 
a  lacrymose  irritability.  While  most  of  the  affects  of  both  depres- 
sion and  exaltation  are  concerned  with  the  ego,  the  afi'ect  of  anger 
differs  markedly  from  these  in  that  it  has  to  do  with  persons  or  objects 
outside  of  one's  self.  At  the  same  time  anger  is  a  depressed  emotion, 
but  with  certain  peculiarities.  In  its  influence  upon  the  flow  of  ideas 
and  upon  action  it  first  retards  or  inhibits,  but  finally,  by  an  accumula- 
tion of  stimuli,  induces  a  sudden  motor  explosion,  which  may  vary  from 
simple  aggressiveness  to  the  most  uncontrollable  fury.  Abbreviation 
of  the  usual  play  of  motives  is  characteristic  of  the  motor  explosions 
of  anger  and  fury.  The  sensory  stimulus  is  carried  directly  into  the 
motor  areas,  without  the  intervention  of  ideas  or  inhibitions,  which 
accounts  for  the  frequent  occurrence  of  outbreaks  of  violence  and 
destructiveness,  followed  by  complete  or  partial  amnesia  as  to  the  acts 
perpetrated. 

Diminution  or  cessation  of  sensory  and  intellectual  emotional  tone 
gives  rise  to  the  condition  known  as  partial  or  general  apathy.  A 
general  apathy  is  frequently  observed  in  neurasthenic  insanity  and  in 
stuporous  states,  but  it  is  more  common  in  certain  cases  of  melancholia. 
Such  patients  will  complain,  paradoxically  as  it  may  seem,  of  a  painful 
feeling  of  having  lost  all  feeling.  They  say  that  they  feel  no  affection 
for  their  children,  no  hope  of  getting  well,  no  pleasure  in  anything,  no 
grief  at   the   loss   of  friends,  that  their   hearts    are    turned  to    stone. 


738  3IENTAL  DISEASES. 

Sometimes  ordinary  sensory  feeling  seems  absent  also,  and  they  say 
they  can  feel  neither  heat  nor  cold,  nor  the  pain  of  a  cut  or  injury. 
One  must  distinguish  between  an  apparent  apathy  and  a  want  of  atten- 
tion consequent  upon  self-centering  of  the  thoughts  on  strong  delusions 
and  hallucinations. 

Partial  apathy  or  limited  defects  of  the  emotions,  as  well  as  of 
special  and  ordinary  sensation,  are  frequently  encountered  in  various 
grades  of  congenital  idiocy  and  acquired  mental  weakness.  Defects  of 
the  higher  forms  of  intellectual  sensory  tone,  the  ethical  feelings,  which 
we  meet  with  in  some  of  these  cases,  constitute  the  so-called  moral  in- 
sanity. 

In  certain  psychoses  a  general  apathy  may  be  so  great  and  the  hori- 
zon of  intellectual  processes  so  narrowed  that  the  condition  amounts  to 
a  pseudodementia  (Magnan),  though  there  is  truly  no  actual  defect  of 
intelligence,  the  mental  functions  being  merely  temporarily  inhibited  or 
suspended. 

A  peculiar  mutability  or  lability  of  aifects  is  not  an  infrequent  phe- 
nomenon in  insanity.  Laughing  and  crying  at  the  same  time  is  not  a. 
rarity  in  persons  who  are  not  insane,  being  the  result  of  the  com- 
mingling of  pleasant  and  distressing  ideas  present  at  the  same  moment 
in  consciousness.  The  emotional  pendulum  swings  quickly  from  one 
extreme  to  the  other.  Such  disequilibration  is  particularly  character- 
istic of  hysteria,  and  is  notable  in  the  hysterical  psychoses.  But  irri- 
tability and  rapid  alternation  of  cheerful  and  pathetic  affects  are  also- 
encountered  in  the  most  various  psychoses.  The  chronic  melancholiac 
with  his  sad  face  and  automatically  repeating  his  set  phrase,  "  I  am 
going  to  be  killed,"  may  laugh  out  suddenly  at  a  funny  incident  and 
immediately  relapse  into  his  habitual  mental  attitude.  In  the  same 
manner  the  paranoiac  may  forget  momentarily  his  persecutory  delusion. 
In  general  paresis  this  swinging  from  one  emotion  to  the  other  in  the 
most  rapid  manner  is  extremely  characteristic.  Mutability  of  affects  is 
indeed  most  common  in  combination  with  conditions  of  intellectual  de- 
fect or  mental  weakness. 


DISORDERS  OF  THE  IDEA-ASSOQATIONS. 

An  idea-association  is  a  psychological  series,  beginning  with  a  stim- 
ulus and  ending  with  a  movement,  between  which  may  be  one  or  two 
or  more  memory-pictures,  some  coming  into  consciousness,  others  re- 
maining latent,  but  all  associated  by  the  nerve-fibers  running  between 
the  ganglion-cells  of  the  cortex  in  which  are  deposited  the  sensory 
impressions.  The  selection  and  serial  course  of  ideas  in  the  stream  of 
thought  are  determined  by  fixed  laws.  One  of  these  is  the  law  of  simi- 
larity-association— i.  e.,  a  sensation  induces  an  idea  (seeing  a  flower  gives 
the  idea  of  a  flower)  and  another  latent  idea  is  aroused  by  this  (a  rose) 
because  the  second  memory-picture  has  marked  similarity  to  the  first 
idea — the  rose  is  remembered  or  recognized.  Every  recognition  contains, 
a  judgment,  since  a  new  sensation  is  seen  to  be  like  a  former  sensation.. 


GENERAL   SYMPT03IAT0L0GY  OF  INSANITY.  739 

Another  law  is  that  of  siinultaneity  of  reception — /.  e.,  memory-pic- 
tures are  associated  when  their  sensory  stimuH  have  been  received  at  the 
same  time.  For  example,  the  sight  of  a  friend  recalls  the  city,  the 
street,  the  house  where  one  first  saw  him,  and  many  others  in  a  highly 
complex  series  of  associations.  Not  all  of  these,  however,  will  arise  at 
sight  of  him.  Perhaps  it  may  be  one  or  two,  perhaps  others ;  so  that 
another  factor  arises — viz.,  the  degree  of  associative  relationship.  Still 
another  factor  is  the  feeling  (the  intellectual  sensory  tone,  the  aifect) 
combined  with  each  of  the  memory-pictures.  Those  memory-jiictures 
will  rise  soonest  into  consciousness  which  are  combined  with  the  live- 
liest emotions,  agreeable  or  disagreeable,  pleasant  or  painful.  Ideas 
with  strong  affects  have  a  greater  chance  in  the  conflict  of  ideas  to  rise 
up  from  their  latency  into  consciousness.  Still  another  feature  of  this 
scheme  is  that  the  latent  ideas  with  their  numerous  associations  influ- 
ence one  another  reciprocally,  some  to  excite  and  some  to  suppress  or 
inhibit.  While  simpler  ideas  are  arranged  in  a  sort  of  serial  association 
one  after  the  other,  on  a  higher  plane  the  successive  memory-pictures 
are  bound  together  into  judgments  and  conclusions.  Ziehen  cites  the 
example  of  the  simple  judgment,  "  The  rose  is  beautiful,"  in  which  we 
have  not  these  ideas  discreetly  ranged  one  after  the  other,  but  the  ideas 
"  rose,"  "  is,"  and  "  beautiful "  stand  in  a  thorough  relation  to  one 
another.  This  form  of  idea-association  is  designated  as  a  judgment-asso- 
ciation. 

The  normal  stream  of  ideas,  or  idea-association,  has  a  definite  swift- 
ness which  varies  in  diiferent  individuals  and  in  the  same  individual  at 
diiferent  times.  In  psychopathology  we  learn  that  agreeable  or  pleasant 
affects  hasten  and  disagreeable  or  unpleasant  aifects  retard  the  flow  of 
thoughts. 

The  pathological  disorders  of  the  idea-association  are  to  be  classified 
as  follows  : 

1.  Disorders  of  memory. 

2.  Disorders  of  attention. 

3.  Accelerated  flow  of  ideas. 

4.  Diminished  flow  of  ideas. 

5.  Disturbance  of  the  connections  between  the  ideas  of  the  idea- 
association  (incoherence). 

6.  Falsification  of  the  judgment-associations  (delusions  and  impera- 
tive ideas). 

7.  Defective  judgment-associations  (weakness  of  judgment). 
Disorders  of  Memory. — Recollection  according  to  the  principle  of 

similarity-association  is  the  calling  up  (by  a  sensation)  of  a  memorj^- 
picture  of  earlier,  similar,  or  identical  sensations. 

Recollection  is  disordered  or  destroyed  by  loss  of  the  necessary 
memory-pictures,  by  any  general  marked  retardation  of  cortical  associa- 
tions, and  by  dissociation  of  the  idea-association. 

Dissociation  is  equivalent  to  incoherence,  and  when  a  general  inco- 
herence exists,  disorder  of  recollection  is  the  rule.  The  patient  then 
confounds  persons  and  objects,  and  often  loses  the  ideas  of  place  and 
time   (a   condition  for  which    unonentation    is   the    best  name).     The 


740  3IENTAL   DISEASES. 

peculiar  paramnesia  observed  in  alcoholic  psychoses,  especially  in  the 
delirium  accomj^anying  alcoholic  neuritis,  is  a  striking  example  of  this 
loss  of  orientation.  The  mistaking  or  confounding  of  persons  and 
things  depends  upon  illusions,  delusions,  incoherence  of  ideas,  lack  of 
distinctness  of  the  requisite  memory-pictures,  or,  finally,  upon  voluntary 
caprices  of  the  patient.  In  alcoholic  paranoia  and  epileptic  insanities, 
and  sometimes  in  other  psychoses,  we  encounter  the  so-called  "  halluci- 
nations of  memory  " — a  bad  term  for  the  phenomenon  experienced  some- 
times by  normal  individuals,  of  having  seen  this  or  that  thing,  or  of 
having  been  in  the  same  place  before,  although  in  fact  the  object  and 
place  are  absolutely  new. 

Disorders  of  Attention. — Condillac  stated  that  if  amid  a  multi- 
tude of  sensations  there  is  one  which  predominates  by  its  intensit}^,  it 
is  thereby  transformed  into  attention.  Ribot  ^  regards  spontaneous 
attention  as  always  caused  by  emotional  states.  The  writer  believes, 
with  Ziehen,  that  attention  is  never  voluntary,  but  always  spontaneous  ; 
that  it  is  the  awakening  of  one  idea  from  the  impressions  of  the  in- 
numerable sensations  impinging  on  our  sensory  surfaces.  Such  atten- 
tion depends  upon  several  factors.  One  is  intensity.  Another  is  cor- 
respondence of  the  received  sensation  with  some  latent  memoiy -picture. 
A  third  factor  is  the  affective  quality  or  sensory  tone  of  the  sensation. 
A  fourth  factor  is  the  combination  of  latent  ideas. 

The  disorders  of  attention  are  morbid  diminution  and  morbid  in- 
crease. The  former  is  extreme  in  idiots,  and  noteworthy  in  patients 
dominated  by  strong  hallucinations  or  overpowering  delusions.  By 
pathological  increase  of  attention  is  meant  the  crowding  of  numerous 
sensations  and  ideas  into  consciousness,  such  as  is  observed,  for  instance, 
in  maniacal  states. 

Accelerated  Flow  of  Ideas. — In  the  highest  degree  of  pathological 
increase  in  the  stream  of  thought  we  observe  not  only  a  rapid  concate- 
nation of  the  associated  ideas,  but  their  swift  transfer  to  the  cortical 
motor  areas,  so  that  gesticulation,  logorrhea,  and  motor  agitation  become 
strikingly  prominent.  It  is  an  ideomotor  excitement.  It  may  be  so 
severe  as  to  present  a  secondary  incoherence.  In  moderate  degrees  of 
acceleration  the  words  spoken  by  the  patient  may,  by  their  sound,  arouse 
associations,  so  that  we  observe  in  the  speech  of  the  patient  a  tendency 
to  rhyming  assonances  and  verbigeration.  The  almost  constant  com- 
bination of  augmented  flow  of  thought  with  an  exalted  and  cheerful 
mood  is  interesting  and,  at  the  same  time,  difficult  to  explain.  Some 
believe  that  the  exaltation  is  due  to  the  patient's  feeling  of  great  facility' 
and  fecundity  of  thought.  Others,  again,  consider  the  exaltation  as  the 
primary  phenomenon,  and  that,  as  in  normal  individuals,  the  exal- 
tation induces  the  free  play  of  ideas.  But  it  is  probable  that  the  cheer- 
ful mood  and  accelerated  flight  of  ideas  are  simultaneous  manifestations 
of  the  morbid  process. 

Diminished  Flow  of  Ideas. — In  this  symptom  we  have  features 
quite  opposite  to  those  manifested   in   ideomotor  excitement.      In  the 

1  "  The  Psychology  of  Attentiou." 


GENERAL  SYMPT03IAT0L0GY  OF  INSANITY.  741 

place  of  increased  we  have  diminished  attention  to  the  sensory  stimulus, 
and  retarded  transfer  of  the  awakened  idea-associations  to  the  motor 
areas  (motor  inhibition).  In  any  noteworthy  inhibition  of  the  flow  of 
thousrht  we  observe  also  difficult  and  retarded  recollection  and  more  or 
less  complete  cessation  of  all  voluntary  movement.  Speech  becomes 
slow,  the  patient  seeking  laboriously  for  Avords,  and  these  are  simply 
whispered,  not  spoken  aloud.  In  severe  degrees  only  slight  move- 
ments of  the  lips  are  made,  or  complete  mutism  is  presented.  Some- 
times a  word  or  phrase  will  l)e  repeated  monotonously  over  and  over ;  a 
single  motion  of  the  arm  or  body  may  be  reiterated  for  hours  (stereotyped 
movements).  The  general  musculature  of  the  body  may  be  completely 
relaxed  and  flaccid  (motor-inhibition  with  resolution)  or  in  a  state  of 
tension  (catatonic  inhibition),  or  in  the  condition  known  as  fiexibilitas 
cerea.  The  condition  designated  as  stupor  comprises  three  cardinal 
symptoms — viz.,  diminished  attention,  thought-inhibition,  and  motor- 
inhibition.  Stupor  may  be  primary  or  secondary.  When  secondary,  it 
is  ordinarily  induced  by  hallucinations  of  ecstatic,  dreadful,  or  impera- 
tive nature.  Stupor  from  ecstatic  hallucinations  is  frequent  in  hysteria 
and  epilepsy,  and  from  dreadful  hallucinations  in  melancholia  (catatonic 
syndrome).     Primary  stupor  is  another  name  for  primary  dementia. 

Depression  with  thought-inhibition  is  common,  and  among  the  de- 
pressed affects  associated  with  it  we  observe  most  frequently  anxiety. 
According  to  the  motor  symptoms  prominent  in  such  cases,  such  as 
flaccidity  (or  resolution),  catatonic  rigidity,  and  restlessness,  we  dis- 
tinguish three  types — viz.,  melancholia  passiva,  melancholia  attonita, 
and  melancholia  agitata.  The  usual  motor  inhibition  is  concealed  in 
melancholia  agitata  by  the  expression  movements  of  anguish,  such  as 
wringing  the  hands ;  picking  the  fingers,  face,  or  scalp  ;  restless  moving 
to  and  fro,  anteroposterior  or  lateral  oscillations  of  the  bodv,  and  the 
like. 

In  the  diagnosis  of  thought-inhibition  we  must  be  careful  to  distin- 
guish, in  the  first  place,  actual  defects  of  intelligence  or  conditions  of 
dementia.  Then  we  must  distinguish  the  primary  form  without  affects 
and  with  affects,  and  the  form  secondary  to  hallucinations  and  delusions. 
Some  of  the  diagnostic  criteria  are  : 

Dementia  and  idiocy  are  stationary  or  progressive  conditions,  while, 
on  the  other  hand,  in  thought-inhibition  there  are  transitory  variations — 
intervals  of  diminished  inhibition. 

Thought-inhibition  is  almost  always  combined  with  motor-inhibition, 
while  this  latter  symptom  is  not  observed  in  defects  of  intelligence. 

The  judgment-associations  in  defective  intelligence  are  also  defective, 
and  wrong  answers  are  often  given  to  questions.  This  is  not  true  of 
states  of  thought-inhibition,  where  correct  answers  are  generally  made, 
if  made  at  all. 

Incoherence. — Incoherence  is  a  dissociation  of  serially  related 
ideas.  Such  dissociation  may  involve  also  the  sensations  which  arouse 
a  series  of  ideas  and  the  motor  sequence  of  a  series  of  ideas.  In  a 
complete  general  incoherence,  then,  the  patient  recognizes  neither  per- 
sons nor  objects,  calls  everything  by  its  wrong  name  (pseudoparaphasia), 


742  MENTAL  DISEASES. 

uses  everything  wrongly  (pseudo-apraxia),  answers  questions  with  abso- 
lute irrelevancy,  and  shows  even  inco5rdination  and  pseudo-ataxia  in 
his  movements.  When  the  incoherence  is  marked  in  the  sensory  percep- 
tions, we  speak  of  lack  of  orientation  ;  it  was  formerly  termed  a  disorder 
of  self-consciousness.  When  the  motor  inco5rdination  is  extreme,  it 
may  amount  to  veritable  jactitation  and  pseudochorea.  Incoherence  is 
most  remarkable,  however,  in  the  speech,  writing,  and  mimetic  expres- 
sion of  the  patient.  The  gestures  and  facial  movements  have  no  rela- 
tion to  the  contents  of  consciousness  ;  laughter  may  accompany  dreadful 
hallucinations  and  a  tearful  countenance  some  jocose  idea.  As  regards 
speech,  if  the  incoherence  is  of  mild  degree,  only  the  sentences  are 
misplaced  ;  if  of  severe  degree,  the  very  words  in  the  sentence  are 
jumbled  together,  and  we  observe  the  phenomenon  of  verbigeration 
and  the  manufacture  of  new  words.  The  handwritmg  of  the  patient 
may  present  the  same  incoherence  as  the  speech.  The  term  confusional 
insanity  has  been  used  to  describe  the  form  in  which  the  symptoms  are 
want  of  orientation,  incoherence  of  ideas,  and  motor  incoherence.  In- 
coherence may  be  primary  or  secondary,  generally  the  latter.  As  a 
primary  phenomenon,  it  is  the  cardinal  symptom  of  the  incoherent  form 
of  paranoia.  Secondary  incoherence  is  due  to  extreme  rapidity  of  the 
stream  of  ideas,  to  accumulation  of  rapidly  changing  delusions  and  hal- 
lucinations, to  strong  depressing  aifects,  and  finally  to  actual  defect  of 
intelligence.  It  is  often  difficult  to  distinguish  primary  from  secondary 
incoherence,  and  far  from  easy  to  differentiate  the  causes  of  the  latter. 

Delusions  and  Imperative  Ideas. — Ideas  are  associated  with  judg- 
ments as  to  similarity,  simultaneity,  properties  of  objects,  etc.,  and  such 
judgment  may  be  correct  or  erroneous  in  normal  individuals,  according 
to  the  weakness  or  strength  of  judgment,  and  according  to  the  degree 
of  correspondence  between  the  sensory  perceptions  and  the  objects  or 
events  of  the  external  world.  The  normal  mind,  however,  generally 
corrects  its  errors  of  judgment  by  repeated  experience  and  better  edu- 
cation— a  physiological  process.  The  pathological  errors  of  judgment 
are  the  delusions  of  the  insane.  These  delusions  are  usually  judgments 
founded  upon  incorrect  sensory  impressions,  such  as  illusions  and  hallu- 
cinations. They  are  rarely  corrected  by  experience,  as  is  the  case  with 
physiological  error.  But  there  are  many  cases  in  which  a  definite 
boundary-line  can  not  be  drawn  between  the  delusions  of  the  sane  and 
those  of  the  insane,  as,  for  instance,  in  the  delusions  of  the  superstitious 
and  of  spiritualists. 

The  delusion  is  the  most  frequent  form  of  pathological  error  of 
judgment,  but  the  imperative  idea  is  also  a  pathological  error  of  judg- 
ment, though  less  commonly  met  with.  Delusions  are  seldom  influenced 
by,  or,  in  fact,  associated  with,  attempts  at  correction  by  the  judgment ; 
whereas  imperative  ideas  are  usually  recognized  as  morbid  by  the  patient, 
but  force  themselves  into  consciousness  despite  the  efforts  of  the  judg- 
ment to  dislodge  them. 

A  delusion  may  arise  in  the  mind  as  a  primary  idea  without  an 
incorrect  sensory  basis,  in  the  same  way  as  an  imperative  idea.  It  may 
be  a  logical  deduction  from  other  delusions,  or,  as  already  stated,  be  the 


GENERAL  SYMPTOMATOLOGY  OF  INSANITY.  743 

product  of  illusions  or  hallucinutions.  It  may  be  the  result  of  a  dream 
carried  over  by  weakened  judgment  into  the  waking  life.  It  may 
develop,  as  in  melancholia  or  mania,  from  the  attempts  of  a  patient  to 
explain  the  origin  of  his  depression  or  exaltation.  Thus,  the  melan- 
choliac  believes  that  his  suliering  must  l)e  due  to  his  bad  conscience,  to 
some  sin  that  he  has  committed,  to  some  serious  disease  of  his  viscera, 
and  the  like.  The  patient  with  exaltation  of  his  emotional  life  develops 
expansive  ideas  as  to  his  strength,  beauty,  intellect,  wealth,  position,  and 
so  on.  The  character  of  delusions  developed  in  the  insane  is  as  multi- 
form as  are  the  ideas  in  the  mind  of  man. 

Depressive  delusions  are  almost  always  connected  with  the  idea  of 
having  committed  a  sin,  of  having  some  disease  (hypochondriasis),  of 
having  lost  all  property,  or  of  persecution.  Contrasted  or  antagonistic 
delusions  of  grandeur  are  sometimes  observed  at  the  same  time  in  con- 
nection with  depressive  delusions.  Thus,  one  patient,  while  weeping  and 
wringing  her  hands,  told  me  she  was  the  queen  of  the  world,  but  was 
unable  to  do  her  duty  because  she  did  not  know  all  languages.  Ziehen 
tells  of  a  patient  who  said,  "  I  was  the  Holy  Ghost.  Had  I  used  my 
omnipotence,  we  would  all  be  happy  now.  But  I  am  cursed.  I  have 
killed  the  Holy  Ghost.  The  whole  world  is  in  misery  and  dread 
through  me."  Hypochondriacal  delusions  generally  arise  from  disorders 
of  common  or  organic  sensibility,  cenesthetic  sensory  impressions, 
though  they  also  develop  from  attempts  at  explanation  of  a  depressed 
mood  and  from  hallucinations.  The  patient  is  certain  he  has  cancer, 
consumption,  syphilis,  brain-softening  ;  that  he  is  impotent ;  that  his 
alimentary  canal  is  closed  up  ;  that  his  brain  has  been  removed  ;  that  his 
viscera  and  tissues  have  been  metamorphosed  into  stone,  glass,  wood, 
and  the  like.  A  peculiar  form  of  hypochondriacal  delusion  is  the  so- 
called  micromania  not  infrequently  observed  in  depressed  periods  of 
general  paresis.  Patients  with  micromania  assert  that  whole  viscera 
have  been  removed  from  their  bodies,  that  their  blood  is  all  gone,  and 
that  they  have  been  reduced  in  size.  Thus,  one  patient  told  me  she  was 
so  small  she  could  l)e  put  into  a  pill-box.  Another  said  his  intestines 
were  absolutely  closed  up  and  he  should  have  to  be  cut  open  to  have 
the  obstacles  removed.  The  delusion  of  pregnancy  arises  from  perver- 
sion of  abdominal  sensory  impressions. 

The  delusion  of  persecution  differs  from  the  other  depressive  de- 
lusions in  that  it  has  to  do  with  the  enmity  of  other  persons  in  the 
environment,  whereas  these  are  concerned  altogether  with  the  ego  of  the 
patient,  his  own  conscience,  his  own  mind,  his  own  body.  The  delusion 
of  persecution  is  important  to  the  general  practitioner,  because  it  is  very 
common,  because  it  is  met  with  so  often  outside  of  institutions,  because 
it  not  infrequently  leads  to  assaults  and  murder,  and  because  its  signifi- 
cance in  prognosis  varies  with  the  species  of  mental  disorder  in  which  it 
is  encountered.  It  is  observed,  for  instance,  in  toxic  insanities  which 
are  curable  ;  in  melancholia,  in  which  cure  is  difficult ;  and  in  paranoia, 
which  is  incurable.  The  most  common  origin  of  the  delusion  of  perse- 
cution is  from  hallucinations.  The  patient  hears  mocking  or  threaten- 
ing voices,  he  tastes  poisons  in  his  food,  he  sees  lowering  looks  and 


744  MENTAL  DISEASES. 

menacing  gestures,  he  feels  singular  sensations  in  his  body  which  must 
be  due  to  irritant  poisons  thrown  upon  him  or  to  electricity,  or  he  smells 
noxious  gases.  The  delusion  of  persecution  may  gro\v  out  of  a  series 
of  hypochondriacal  delusions,  in  the  attempt  of  the  patient  to  explain 
the  origin  of  his  miseries.  It  may  arise  also  from  the  delusion  of 
having  committed  a  sin  or  crime,  the  patient  imagining  that  every  one 
hates  him  and  follows  him  to  punish  him.  Sometimes  these  persecutory 
delusions  are  referred  to  the  influence  of  unseen  agencies — hypnotism, 
telepathy,  electricity,  magnetism.  Sometimes  they  have  to  do  with  the 
property  or  social  position  of  the  patient ;  he  Ijelieves  his  belongings  are 
being  stolen,  or  his  character  maligned.  Sometimes  erotic  ideas  are 
bound  up  with  persecutory  ideas ;  a  woman  believes  herself  secretly 
cohabited  with  at  night,  or  even  by  day,  through  occult  means ;  a  man 
thinks  he  is  made  impotent,  that  his  seminal  fluid  is  being  drawn  off. 
Obviously,  these  latter  ideas  often  rest  upon  perverted  sensory  impres- 
sions received  from  the  sexual  organs.  In  seeking  to  discover  the 
origin  of  the  persecution,  the  patient  often  at  first  settles  upon  some  one 
definite  individual,  but  later,  when  he  finds  the  methods  of  persecution 
innumerable  and  that  his  enemies  follow  him  wherever  he  goes,  he  can 
not  believe  that  any  one  person  could  do  so  much  ;  he  reaches  the  con- 
clusion that  it  must  be  a  wide-spread  conspiracy,  such  as  could  be  carried 
out  only  by  some  large  affiliation  of  persons,  such  as  societies  of  Free- 
masons, anarchists,  Jesuits,  lawyers,  and  police.  The  delusion  of  per- 
secution occasionally  develops  from  a  delusion  of  grandeur ;  the  patient 
believes  he  is  persecuted  because  of  his  wealth  or  exalted  position. 
More  often,  however,  the  contrary  is  the  case,  the  patient  coming  to 
believe  himself  some  extraordinary  personage  because  of  the  persecu- 
tions to  which  he  is  subjected. 

Another  interesting  form  of  depressed  delusion  is  that  of  negation 
{delire  de  negation  generalise),  which  has  its  origin  usually  from  an  idea 
of  having  sinned.  The  patient  thinks  he  must  be  the  devil  himself,  his 
sin  is  so  great ;  consequently  he  can  never  die,  he  must  suffer  forever ; 
then,  with  the  growing  idea  of  the  enormity  of  his  sin,  he  comes  to 
believe  that  God  and  mankind  and  the  world  exist  no  more. 

Delusions  of  grandeur  vary  from  simple,  expansive  ideas  of  the 
patient's  importance,  prerogatives,  and  powers,  to  delusions  of  being 
inventors,  geniuses,  prophets,  reformers,  titled  and  royal  personages,  and 
even  Christ,  God,  and  the  mother  of  God.  Besides  his  owm  person- 
ality, his  environment  maybe  vested  with  grandiose  qualities — his  room 
a  palace,  his  straw  hat  a  crown,  pebbles  diamonds,  his  children  prin- 
cesses, and  so  on.  A  peculiarity  of  the  ideas  of  grandeur  observed  in 
general  paresis,  which  is  quite  pathognomonic,  is  their  enormity  or, 
rather,  monstrosity.  It  is  not  enough  to  be  wealthy,  but  sextillioiis  of 
planets  can  not  hold  the  gold  and  jewels.  It  is  not  sufficient  to  have  a 
dozen  children,  but  billions  of  children  are  given  birth  to  nightly  bv  his 
innumerable  wives.  He  will  make  a  new  Niagara,  by  bringing  the 
Pacific  Ocean  over  the  Andes.  Should  sexual  ideas  prevail,  he  may 
say  that  his  penis  is  a  mile  long,  and  his  testicles  are  huge  diamonds. 
He  will  move  the  asvlum  across  the  United  States  on  a  road  of  solid 


GENERAL   SYMPTOMATOLOGY  OF  INSANITY.  745 

gold.  Such  enormities  betoken  great  weakening  of  tlie  intellect  and 
judgment. 

Primary  delusions  conduce  more  to  fixity  than  delusions  secondary 
to  hallucinations.  The  latter,  depending  as  they  do  upon  the  staljility 
or  instability  of  the  morbid  sensory  impressions,  change  with  these. 
A\'hen  delusions  become  lixed,  they  tend  to  crystallize  or  become  sys- 
tematized. Systematization  consists  of  cond)ining  Avith  the  fixed  idea 
complementary  delusions  in  a  more  or  less  logical  order  or  of  the  fan- 
tastic elaboration  of  the  original  delusion.  The  degree  of  organization 
and  perfection  of  the  delusional  structure  will  depend  upon  fancy, 
logical  faculty,  social  position,  and  education  of  the  jtatient.  Tlie  most 
common  form  of  systematization  is  in  the  development  of  secondary 
grandiose  ideas  upon  a  persecutory  basis.  But  almost  any  of  the  de- 
pressed and  exalted  delusions  previously  described  may  Ijecome  fixed, 
systematized,  and  permanent  through  the  life  of  the  patient. 

Delusions  may  have  a  retroactive  effect  in  awakening  sensory  im- 
pressions, instead  of  being  aroused  by  them — that  is,  may  induce  illu- 
sions and  hallucinations.  For  example,  the  persecuted  patient  perceives 
voices,  odors,  tastes,  pains,  etc.,  often  because  of  his  mind  being  in  a 
state  of  expectant  attention. 

Imperative  ideas  force  themselves  into  consciousness  in  spite  of 
the  efforts  of  the  patient — who  recognizes  their  morbid  character — to 
correct  them.  They  are  accompanied,  almost  without  exception,  by  a 
depressive  affect,  a  painful  sensory  tone.  They  are  extremely  common 
in  neurasthenia.  Senseless  phrases  or  doggerel  repeat  themselves  over 
and  over  in  the  patient's  mind.  The  many  varieties  of  phobia  are 
familiar  examples  of  imperative  ideas  in  neurasthenics  (agoraphobia, 
claustrophobia,  mysophobia,  etc.).  Imperative  ideas  are  also  observed 
in  melancholia  and  in  a  form  of  insanity  which  has  been  designated  as 
insanity  from  imperative  ideas.  In  very  rare  instances  they  are  en- 
countered in  early  stages  of  general  paresis.  They  always  develop  on 
the  basis  of  a  congenital  or  acquired  neuropathic  or  psychopathic  con- 
stitution, and  are  apt  to  become  obstinate  features  in  the  mental  organi- 
zation. Almost  every  imperative  idea  has  its  inception  in  some  sort  of 
sensory  impression,  and  the  idea  may  lead  to  compulsory  actions  on  the 
part  of  the  patient.  But  between  the  imperative  idea  and  the  conse- 
quent action  there  is  generally  a  play  of  judgment,  a  faltering  between 
the  imperative  idea  and  antagonistic  or  inhibiting  concepts.  For 
instance,  the  patient  feels  a  compulsion  to  lock  a  door  which  he  feels 
sure  he  has  already  locked.  After  an  inward  debate  as  to  whether  he 
should  go  back  and  assure  himself  that  it  is  locked,  which  may  last 
many  minutes  of  longer,  he  goes  to  lock  it,  and  on  leaving  the  door 
again  tlie  imperative  idea  arises  that  it  is  not  locked.  The  same  play 
of  antithetic  ideas  may  occur  in  reference  to  anything — the  addressing 
of  a  letter,  the  return  of  a  book  to  a  shelf,  acts  of  dressing  and  un- 
dressing, the  crossing  of  a  street,  etc.  In  some  cases  the  imperative 
idea  takes  the  form  of  compulsion  to  jump  from  a  height,  to  laugh  in 
unseemly  places  ;  or  obscene  and  sacrilegious  words,  sentences,  and  fan- 
cies may  thrust  themselves   obstinately   into  the  consciousness.      For 


746  MENTAL   DISEASES. 

example,  a  gentleman,  and  a  good  Christian,  came  to  me  recently  over- 
whelmed with  the  sacrilegious  conceptions  which  first  came  to  him  at  a 
church-service  a  week  or  two  before — ideas  of  cohabitation  with  the 
Virgin  Mary  and  filthy  expressions  in  relation  to  Christ.  A  lady  con- 
sulted me  about  a  morbid  fear  that  she  had  of  canary  birds.  She 
could  not  enter  a  house  or  hotel  in  which  there  was  a  canary  bird, 
because  she  was  afraid  that  bird-seed  might  get  about  and  in  some  way 
get  into  her  mouth,  be  swallowed,  and  grow  in  her  stomach.  The  con- 
tents of  these  imperative  concepts  are  as  varied  as  those  of  delusions, 
though  they  are  almost,  without  exception,  trivial  or  unpleasant. 

Folie  du  doute  is  a  form  of  mental  disorder  in  which  compulsory 
ideas  assert  themselves  in  the  form  of  questions,  religious,  metaphysi- 
cal, or  in  regard  to  the  most  trivial  things  or  events  (Shall  I  do  this  or 
that  ?  Why  is  the  table  round  ?  Why  is  the  chair  by  the  bed  ?  Why 
are  two  and  two  four  ?).  One  young  lady  is  so  incapable  of  deciding 
any  question  that  comes  up  in  her  mind  that  she  does  not  know 
whether  she  ought  to  dress  or  undress,  go  to  bed,  eat,  sleep,  pray,  or 
consult  a  doctor.  Every  trivial  question  of  the  day  requires  hours 
of  painful  and  agonizing  debate  in  her  mind. 

Imperative  ideas  frequently  impel  to  compulsory  speech  and  actions. 
Coprolalia  is  a  not  uncommon  form  of  imperative  speech  in  which  the 
patient  is  impelled  to  the  utterance  of  obscene  words.  Quite  analo- 
gously the  patient  may  be  made  to  make  grimaces,  or  may  develop  the 
so-called  maladie  des  tics. 

Weakness  of  Judgment. — Innumerable  memory-pictures  and 
associated  ideas  take  part  in  the  process  of  comparison  and  decision 
which  we  know  as  judgment.  Hence  any  disorder  of  memory  and  of 
its  associations,  such  as  loss,  defect,  or  perversions  (delusions,  hallucina- 
tions, or  illusions),  must  naturally  influence  the  character  of  the  judg- 
ment. One  of  the  common  conditions  which  impairs  judgment  is, 
therefore,  intellectual  defect,  such  as  congenital  or  acquired  mental 
weakness.  The  criteria  of  idiocy  and  dementia  are  poverty  of  ideas 
and  idea-associations  and  weakness  of  judgment.  When  delusions  or 
imperative  ideas  exist,  the  errors  of  judgment  are  due  to  the  overriding 
and  eclipsing  by  single  ideas  and  idea-associations  of  all  others  which 
would  in  the  normal  mind  give  balance,  control,  and  revision  to  the 
judgment.  Defective  judgment  varies  in  degree  from  a  slight  loss  of 
the  critical  faculty  to  complete  deficiency.  When  the  judgment  is 
markedly  defective,  it  depends  upon  actual  organic  changes  in  the 
brain,  such  as  we  observe  in  idiocy,  terminal  dementia,  senile  dementia, 
and  general  paresis,  and  hence  as  a  symptom  it  is  far  more  ominous 
than  delusions  and  imperative  ideas,  which  usually  rest  upon  a  func- 
tional pathological  basis.  Its  significance,  then,  demands  a  careful 
differentiation  of  this  symptom  from  others  with  which  it  might  be 
confused,  such  as  incoherence  and  thought-inhibition.  In  incoherence 
the  threads  of  thought  are  constantly  lost.  In  thought-inhibition  there 
are  a  depressive  aifect  and  extraordinary  slowness  of  association  with 
correspondingly  tardy  answers,  and,  besides,  there  are  variations  of  depth 
of  inhibition,  so  that  at  times  complicated  answers  and  judgments  are 


GENERAL   SYMPTOMATOLOGY  OF  INSANITY.  747 

readily  given.  In  actual  weakness  of  judgment  the  judgments  ren- 
dered are  false,  and  the  more  incorrect,  the  more  complicated  the 
questions. 

DISORDERS  OF  ACTIONS. 

The  actions  or  conduct  of  a  patient  depend  directly  and  necessarily 
upon  pathological  elements  in  some  part  of  the  psychological  processes 
— sensation,  memory-pictures,  idea-associations,  and  their  emotional 
affects.     They  may  be  classified,  following  Ziehen,  as — 

1.  Actions  induced  by  .sensory  disorders. 

2.  Actions  induced  by  disorders  of  memory. 

3.  Actions  induced  by  disorders  of  the  emotions. 

4.  Actions  induced  by  disorders  of  the  idea-association. 

Actions  Induced  by  Sensory  Disorders. — Hallucinations  and 
illusions  affect  the  conduct  of  a  patient  often  markedly,  and  their  influ- 
ence is  always  greater  than  that  of  normal  sensations.  Their  dominance 
is  the  greater  in  proportion  to  their  number  and  to  the  rapidity  of  their 
accumulation.  Hallucinations  gathered  slowly  in  the  course  of  weeks 
or  months,  while  they  may  not  be  corrected,  are  at  least  subject  to  a 
certain  amount  of  control  by  the  inhibition  of  normal  ideas.  In  the 
most  chronic  forms  of  hallucination  the  voices,  common  sensations,  and 
visions  tend  to  be  ignored  and  to  influence  to  a  very  slight  degree  the 
conduct  of  the  patient.  A  very  important  practical  feature  in  regard  to 
hallucinations  and  their  effects  upon  conduct  is  their  uncertainty.  They 
are  never  to  be  reckoned  with,  and  one  can  never  know  what  sudden 
violence  or  destructiveness  may  result  from  new  hallucinations  rising  in 
the  patient's  brain. 

Actions  Induced  by  Defects  of  Memory. — These  are  observed  in 
congenital  or  acquired  weak-mindedness,  where  the  conduct  is  directly 
ordered  by  sensory  impressions,  without  that  intervention  of  the  play 
of  motives  which  we  observe  in  normal  individuals.  They  are  more 
like  the  actions  of  the  lower  animals,  which  may  be  complete  enough  in 
their  way,  but  are  not  motived  by  complicated  abstract  conception^, 
because  these  are  wanting. 

Actions  Induced  by  Disorders  of  the  Emotions. — As  already 
elsewhere  intimated,  simple  depressed  emotions  are  accompanied  by  a 
general  motor  inhibition,  and  simple  exalted  emotions  by  a  general 
motor  agitation.  But  when  the  depressed  affect  attains  to  the  degree  of 
anxious  dread,  w^e  may  have  a  restlessness,  a  desire  for  flight,  which  in 
itself  amounts  to^a  motor  agitation.  This  anxious  state  often  leads  to 
suicidal  attempts,  and  even  to  homicidal  assaults,  arson,  and  other  forms 
of  crime  and  violence.  The  whole  nervous  system  seems  to  be  in  such 
a  state  of  tension  that  only  an  explosion  can  give  relief. 

In  apathetic  conditions  action  is  reduced  to  its  minimum. 

AVhere  the  higher  affects,  which  are  at  the  basis  of  ethical  concepts, 
are  absent  or  lost,  as  in  congenital  or  acquired  states  of  mental  weak- 
ness, crimes  against  person  and  property  are  common. 

In  conditions  of  anger  and  rage  there  is  at  first  a.  brief  period  of 


748  MENTAL   DISEASES. 

speechlessness  and  immobility,  followed  by  an  explosion  of  blind  and 
violent  motor  excitement,  in  which  the  most  dangerous  assaults  may  be 
made. 

In  conditions  of  changeability  or  lability  of  the  emotions,  we  ob- 
serve analogous  motor  states — sudden  changes  from  weeping  and  wailing 
to  boisterous  cheerfulness,  and  vice  versa. 

A  study  of  emotional  expression  is  of  particular  diagnostic  value  in 
insanity,  but  the  features  of  such  expression  and  gesticulation  are  so 
well  known  that  they  need  no  detailed  description  here.  Each  mood, 
be  it  simple  depression,  anxious  terror,  excitation,  anger,  apathy,  or 
emotional  lability,  has  its  own  familiar  motor  habiliments. 

Actions  Induced  by  Disorders  of  the  Idea-association  or  Stream 
of  Thought. — Under  this  heading  are  gathered  the  multiform  modes 
of  action  caused  by  increase  in  the  flow  of  ideas,  retardation  of  the 
stream  of  thought,  incoherence,  delusions,  imperative  ideas,  and  weak- 
ness of  judgment. 

In  increased  rapidity  of  the  flow  of  ideas  we  note  motor  agitation 
or  morbid  impulse  to  movement,  varying  from  simple  talkativeness, 
with  active  play  of  expression,  to  loud  garrulity,  grimaces,  gesticula- 
tion, busy  walking  about,  running,  dancing,  and,  in  extreme  degrees,  to 
undressing,  destructiveness  of  clothing,  bedding,  furniture,  and  blind 
throwing  about  of  the  body  in  every  conceivable  way.  This  so-called 
primary  motor  agitation  should  be  distinguished  from  the  motor  agita- 
tion which  is  secondary  to  crowding  hallucinations  (hallucinatory  agita- 
tion) and  to  emotions  like  terror  and  anger  (affective  agitation). 

The  behavior  of  the  movements  in  regard  to  retarded  flow  of  thought 
has  already  been  briefly  alluded  to.  There  is  a  general  motor  inhibition, 
varying  from  simple  slowness  and  difficulty  of  executing  any  movement, 
whether  of  speech  or  other  muscles,  to  a  complete  cessation  of  volun- 
tary movements,  a  stuporous  or  attonitous  condition,  in  which  the 
muscles  may  be  absolutely  at  rest  and  flaccid  or,  on  the  other  hand, 
in  a  condition  of  catatonic  tension.  In  true  catatonic  tension  every 
attempt  at  passive  movement  is  resisted,  but  in  another  form  of  this 
there  is  a  waxy  flexibility  of  the  muscles,  so  that  the  limbs  yield  readily 
to  any  passive  motion,  remaining  in  whatever  position  the  physician 
desires  to  place  them.  Occasionally  one  encounters  in  cases  of  retarded 
idea-associations,  as  an  expression  of  motor  inhibition,  a  tendency  to  the 
repetition  of  some  restricted  voluntary  movement  in  a  rhythmical, 
stereotyped  way  for  days,  weeks,  months  at  a  time.  Such  stereotyped 
motions  may  be  simple  anteroposterior  oscillations,  lateral  oscillations, 
whirling,  walking  to  and  fro  or  in  a  circle,  waving  the  hands  rhythmi- 
cally— forms  of  tics  exceedingly  common  in  idiocy  and  imbecility, 
but  common  enough  in  melancholias  and  terminal  dementias.  The 
repetition  of  stereotyped  or  automatic  phrases  is  analogous  in  character 
to  such  morbid  movements.  Motor  inhibition  is  primary  or  secondary. 
The  primary  form  is  generally  a  simple  resolution  or  flaccidity,  occa- 
sionally a  slight  catatonic  tension  or  flexibilitas  cerea.  Secondary  motor 
inhibition  is  due  to  hallucinations,  delusions,  and  states  of  mental  weak- 
ness. 


GENERAL   SYMPTOMATOLOGY  OF  INSANITY.  749 

Incoherence  of  ideas  leads  to  a  dissociation  also  in  the  motor  ex- 
pressions of  ideas,  parapraxia,  paramimia,  incoordination,  pseudo-ataxia, 
incoherent  agitation,  chorea  magna,  and  jactitation.  Such  motor  agita- 
tion may  be  primary  or  may  be  the  secondary  result  of  innumerable 
clashing  hallucinations  and  delusions,  rapidity  of  the  flight  of  ideas  or 
of  intellectual  defects. 

Grandiose  delusions  exert  their  own  peculiar  influence  on  the 
demeanor  and  speech  of  the  patient,  according  to  the  contents  of  the 
exalted  ideas.  We  observe  the  proud  bearing ;  the  self-sufficient, 
haughty,  or  secret  smile  ;  the  withdrawing  from  others  ;  the  tendency  to 
decoration  of  the  person  ;  the  attempts  to  act  the  parts  of  the  personage 
he  imagines  himself  to  be  ;  the  striking  peculiarities  of  handwriting. 
In  some  instances  delusions  of  grandeur  lead  to  homicidal,  rarely 
suicidal,  attempts  (self-crucifixion  with  the  delusion  of  being  Christ). 
Grandiose  erotic  ideas  sometimes  occasion  masturbation.  Coprophagy 
and  other  filthy  habits  may  depend  upon  grandiose  delusions  as  to 
extraordinary  virtues  of  the  patient's  excretions. 

In  depressed  delusions,  particularly  as  regards  ideas  of  sin  and 
poverty,  we  observe  the  characteristic  melancholy  facial  expression 
and  attitudes.  Attempts  at  suicide  are  frequent,  and  sometimes 
self-mutilation.  Abstention  from  food  is  especially  common  with 
the  delusion  of  poverty,  the  patient  feeling  that  he  can  not  pay  for 
anything. 

Hypochondriacal  ideas  influence  markedly  the  patient's  actions  and 
conduct.  The  hypochondriac  may  neglect  every  duty  in  the  constant 
contemplation  of  his  symptoms.  He  reads  medical  books,  goes  from 
one  physician  to  another,  takes  to  his  bed  perhaps  permanently,  and  so 
on.  The  effects  of  hypochondriasis  on  motor  functions  are  frequently 
remarkable,  leading  sometimes  to  astasia  or  abasia,  or  both  ;  to  hypo- 
chondriacal ataxia,  tremor,  or  convulsive  movements  of  the  extremities. 
These  hypochondriacal  motor  conditions  are  ahvays  the  result  of  a  series 
of  morbid  judgments  on  a  hypochondriacal  basis,  and  are  to  be  distin- 
guished from  similar  hysterical  states  which  have  an  autochthonous  origin 
without  any  antecedent  conscious  reasoning  process. 

The  persecutory  delusions  lead  to  systems  of  self-protection  of  the 
most  varied  kind.  Barricades,  stopping  up  of  cracks  and  keyholes, 
the  wearing  of  peculiar  clothing  (silk,  paper,  etc.,  for  instance,  as  a 
guard  against  electrical  shocks),  avoiding  of  food  and  drink  which  are 
suspected  of  containing  poison,  arming  with  weapons,  frequent  change 
of  servants  or  residence,  and  complaints  to  the  police  or  judicial 
authorities.     Homicide  is  common  in  these  cases. 

Imperative  ideas  lead  to  imperative  movements  and  actions,  and 
generally  in  spite  of  the  well-preserved  consciousness  and  judgment  of 
the  patient.  Such  imperative  actions  are  as  various  in  character  as  the 
imperative  ideas  to  which  they  correspond.  ^ 

Accompanying   Physical  Disorders  in  Insanity. — Among  the 

^  The  foregoing  account  of  the  psychopathology  of  insanity  is  largely  a  presenta- 
tion of  the  views  of  Ziehen,  to  whose  excellent  work  the  author  must  refer  readers  for 
greater  detail. 


oO 


MENTAL   DISEASES. 


many  somatic  symptoms  which  may  complicate  or  accompany  psychoses 
are  chiefly  to  be  mentioned  the  following  : 

1.  Motor  disorders. 

2.  Sensory  disorders. 

3.  Reflex  disorders. 

4.  Trophic  disorders. 

5.  Secretory  and  excretory  disorders. 

6.  Temperature  disorders. 

7.  Vascular  disorders. 

Motor  Disorders. — These  may  be  manifested  in  the  form  of  morbid 
movements  or  paralysis.  In  the  first  category  are  assembled  such 
symptoms  as  epilepsy,  convulsions,  chorea,  choreiform  movements, 
tremor,  tics,  ataxia,  masticatoiy  sj)asm,  and  the  like.  The  following 
table,  modified  from  Ziehen,  gives  a  general  summary  of  the  paralytic 
symptoms  noted  in  insanity  : 


FOEM    or 
Paealysis. 

Character. 

Trophic 
Disturbances. 

Spasticity 

OR 

Flaccidity. 

Sensory 
Disorders. 

Deep 
Eeflexes. 

Hypochon- 
driacal. 

Usually  limited 
to     a    certain 
form  of  move- 
ment. 

No  atrophy. 

Flaccidity. 

None. 

Normal. 

Hysterical. 

M  o  n  0  p  1  e  g  ia, 
hemiplegia,  or 
paraplegia. 

Disuse  atro- 

Frequently 
contractures. 

Hemianes- 
thesias, etc. 

Normal     or 
hypertypical. 

Cortical. 

Monoplegia    or 
hemiplegia. 

Disuse  atro- 
phy. 

Eigidity,  con- 
tractures, lo- 
cal spasms. 

Paresthesias, 
occasionally 
anesthesias. 

Exaggerated 
usually. 

Pyramidal 
tract. 

Hemiplegia   or 
paraplegia. 

Disuse  atro- 

piiy- 

Spasticity, 
contractures 
frequently. 

Occasionally 

anesthesia, 
hemianop- 
sia, etc. 

Exaggerated. 

Peripheral. 

Multiple  or  sin- 
gle. 

True  atrophy 
with  degen- 
erative   re- 
action. 

Flaccidity. 

Hyperesthes- 
ias, stocking 
and  glove 
areas  of  an- 
esthesias 
often. 

Lost. 

Sensory  Disorders. — Anesthesias  and  hyperesthesias  have  already 
been  mentioned,  but  hyperalgesias  and  paresthesias  of  divers  kinds  are 
encountered  among  the  psychoses,  such  as  headache,  migraine,  neural- 
gias, feeling  of  fullness  in  the  head,  scotomata,  tinnitus  aurium,  and  so 
on.  Neuralgia  is  occasionally  a  cause  of  insanity.  Migraine  is  a  fre- 
quent precursor  of  general  paresis  and  concomitant  of  epilepsy.  Light- 
ning pains  are  noted  in  tabic  types  of  dementia  paralytica.  Neurasthenic 
pains  and  paresthesias  in  the  extremities,  spine,  and  head  are  found  in 


GENERAL   SYMPTOMATOLOGY  OF  INSANITY.  751 

neurasthenic  forms  of  insanity.  Where  hysteria  complicates  a  psychosis, 
there  are  often  observed  the  sensory  disturbances  characteristic  of  that 
malady. 

Reflex  Disorders. — Changes  in  the  reflexes  are  important  in  but  a 
few  forms  of  insanity.  In  paralytic  dementia  we  observe  nearly  always 
exaggerated  tendon-reflexes,  but  in  tabic  types  they  are  lost.  They  are 
lost  also  in  psychoses  complicated  with  multiple  neuritis,  and  frequently 
in  cases  with  diabetes,  and  in  morphinomania.  The  deep  reflexes  are 
exaggerated  in  senile  dementia,  many  acute  affective  insanities,  hysteria, 
epilepsy,  and  in  patients  with  accompanying  multiple  sclerosis.  The 
state  of  the  superficial  reflexes  possesses  little  significance,  except  in  in- 
sanity associated  with  hysteria  and  organic  disorders  of  the  brain,  spinal 
cord,  or  peripheral  nerves. 

The  Argyll-Robertson  pupil  is  met  with  almost  constantly  in  gen- 
eral paresis.  The  pupils  in  all  cases  of  insanity  should  be  examined  as 
to  their  equality,  size,  and  reaction  to  light,  and  in  accommodation. 
Loss  of  reaction  to  light  may  be  observed,  besides,  in  general  paresis,  in 
syphilitic  insanities,  senile  insanity^  and  in  some  alcoholic  cases ;  it 
means  organic  disease  of  the  brain.  In  rare  instances  a  transitory 
rigidity  of  the  pupil  occurs  in  epilepsy  and  morphinomania.  Inequality 
of  pupils  is  very  common  in  organic  and  occasional  in  functional  in- 
sanities. 

Trophic  Disorders. — General  disturbances  of  nutrition,  variations 
in  bodily  weight,  are  commonly  noted,  and  possess  considerable  signifi- 
cance. Thus,  rapid  increase  in  weight  is  characteristic  of  the  progress  of 
an  acute  psychosis  to  terminal  dementia ;  if,  however,  it  accompanies  an 
improvement  in  mental  symptoms,  it  betokens  convalescence.  In  some 
cases  enormous  decrease  in  weight,  in  association  with  pernicious  anemia, 
leads  to  a  fatal  termination.  Certain  forms  of  insanity,  especially 
organic,  notably  paralytic  dementia,  present  a  remarkable  trophic 
disturbance  in  the  bones,  a  fragilitas  ossium,  inducing  easy  fracture. 
Decubitus  is  observed  in  bedridden  insane  patients,  particularly  paretics. 

Hematoma  auris,  othematoma,  or  the  "  insane  ear,"  is  a  deformity 
of  the  ear  produced  by  a  hemorrhage  into  the  substance  of  the  auricle, 
usually  between  the  perichondrium  and  the  cartilage.  It  is  undoubtedly 
traumatic  in  its  origin,  but  there  is  fundamentally  some  change  in  the 
vascular  walls  in  certain  cases  of  chronic  insanity,  rendering  them 
fragile  and  easily  ruptured  by  the  most  trivial  pressure  or  injury. 
Such  effusions  of  blood  do  occur  in  normal  individuals  (athletes  and 
boxers),  but  always  from  severe  trauma.  The  frequency  of  hematoma 
auris  in  general  paralysis,  and  in  many  chronic  forms  of  insanity  is 
only  explicable  t>n  the  hypothesis  of  some  trophic  change  in  the  vessel- 
walls. 

Secretory  Disorders. — The  secretion  of  tears  is  generally  reduced 
or  absent  in  melancholia. 

The  saliva  may  be  diminished  in  quantity  in  melancholia.  More 
often  in  many  forms  of  insanity  it  is  increased,  the  excessive  secretion 
amounting  sometimes  to  a  sialorrhea.  The  increase  is  due  to  constant 
mastication,  to  illusions  and  hallucinations  of  taste,  and  sometimes  to 


752  MENTAL  DISEASES. 

irritative  stimuli  in  the  secretory  centers.  Drooling  may  give  the  ap- 
pearance of  an  increase  of  salivary  flow,  because  of  relaxation  of  the 
oral  and  buccal  muscles,  or  l)ecause  the  secretion  is  not  swallowed. 

Diminution  or  increase  of  hydrochloric  acid  in  the  gastric  juice  is 
noted  in  many  cases  of  insanity,  and  the  quantity  may  be  determined 
by  the  Sjijqvist  method.  Hypochlorhydria  exists  in  common  in  states 
of  congenital  and  acquired  intellectual  defect  and  in  general  paresis. 
Hvperchlorhydria  is  not  infrequently  met  with  in  cardialgic  attacks, 
after  epileptic  seizures,  and  in  catatonic  conditions. 

As  regards  the  urine,  quantitative  and  qualitative  changes  are  very 
common  in  insanity.  These  changes  may  be  the  expression  of  abnormal 
metabolism  in  the  central  nervous  system,  of  abnormal  metabolism  in 
other  parts  of  the  body  induced  by  disease  of  the  central  nervous  sys- 
tem, or  of  vasomotor  changes  in  the  kidneys  brought  about  by  the 
psychoneurosis.  Polyuria  is  observed  in  many  organic  psychoses  and 
in  hysterical  complications.  Oliguria  is  characteristic  of  melancholy 
and  stuporous  conditions.  In  hysterical  insanity  there  is  frequently  an 
alternation  between  oliguria  and  polyuria. 

As  regards  the  qualitative  changes  in  the  urine  of  the  insane,  we 
are  year  by  year  recognizing  more  and  more  the  im|)ortance  of  investi- 
gation in  this  direction.  There  is  no  doubt  that  the  deeper  our  re- 
searches go  into  the  chemistry  of  metabolism  and  catabolism,  the 
nearer  do  we  attain  to  a  better  understanding  of  the  mysterious  nutri- 
tional processes  that  have  to  do  with  the  construction  of  the  blood  and 
that  underlie  so  many  psychoses.  Albumin,  peptone,  and  propeptone 
are  found  not  infrequently  in  the  urine  of  cases  of  organic  insanity,  in 
delirium  tremens,  in  epilepsy,  and  in  acute  mania.  Their  presence  is 
often  transitory,  and  unaccompanied  by  renal  disease.  Hyalin  cylinders 
are  also  often  observed  in  severely  excited  conditions. 

Excessive  phosphaturia  is  noteworthy  in  many  cases  of  great  cere- 
bral excitement,  and  after  epileptiform  and  apoplectiform  seizures.  In 
chronic  brain  disorders  the  quantity  of  phosphoric  acid  is  diminished 
below  the  normal. 

The  chlorids  are  lessened  in  quantity  in  melancholia.  They  are 
increased  in  the  early  stages  of  paresis,  but  diminish  with  the  progress 
of  the  disease  to  dementia. 

Sulphates  and  the  aromatic  ethereal  sulphates  (the  latter  being  the 
product  of  destructive  proteid  metabolism)  are  increased  in  febrile  con- 
ditions, and  in  conditions  attended  with  much  tissue-waste. 

Urea  is  also  representative  of  destructive  proteid  metabolism,  and  is 
an  index  of  the  general  nitrogenous  metabolism  of  the  body.  It  is 
increased  in  conditions  associated  with  tissue-waste,  diminished  in  states 
of  malnutrition.  Uric  acid  and  the  urates  have  much  the  same  rela- 
tion. 

Oxaluria  (any  increase  above  the  normal  amount  excreted  in  twenty- 
four  hours — viz.,  -^-^  of  a  grain)  is  observed  in  certain  nervous  and 
mental  disorders,  l:)ut  its  precise  significance  still  requires  determination. 

Uroljilinuria  and  bilirubinuria  have  occasionally  been  noted  in  gen- 
eral paresis. 


GENERAL  SYMPTOMATOLOGY  OF  INSANITY.  753 

Glycosuria,  with  or  without  polyuria,  has  often  been  observed  in 
various  organic  psychoses.  It  may  be  intermittent,  transitory,  or  per- 
manent. 

Acetonuria  is  encountered  in  general  paresis  and  epilepsy  at  times,  as 
also  in  psychoses  attended  with  malnutrition,  as,  for  instance,  melancholia. 

Indican  should  be  sought  for,  as  it  is  an  -  indication  of  albuminous 
putrefaction.      It  is  significant  of  auto-intoxication. 

There  is  a  wide  region  open  to  the  pathological  chemist  for  discov- 
eries in  the  feces,  as  well  as  the  urine,  of  relations  between  metabolism 
and  psycopathic  disorders. 

Menstt'uaiion  is  often  disordered  in  insanity.  Amenorrhea  is  the 
rule  in  acute  psychoses  of  any  form,  due  undoubtedly  to  profound 
changes  in  the  general  nervous  system  influencing  the  spinal  centers  for 
ovulation  and  menstruation.  The  cessation  of  menstruation  with  the 
onset  of  an  acute  psychosis  is  often  mistakenly  supposed  by  the  laity  to 
show  some  etiological  relation  between  the  genital  organs  and  the  in- 
sanity. The  return  of  the  menses  is  one  of  the  early  signs  of  con- 
valescence from  acute  mania  and  acute  melancholia.  Naturally,  it 
would  not  be  correct  to  ascribe  amenorrhea  in  all  cases  to  simply  ner- 
vous inhibition,  because  it  may  arise  in  all  kinds  of  psychoses  as  the 
result  of  actual  genital  disease  or  of  marked  anemia. 

Temperature-changes  in  Insanity. — The  physiological  oscillations 
of  temperature  are  greater  and  more  irregular  in  the  insane  than  in 
normal  individuals.  In  general,  however,  insanity  may  be  said  to  run 
a  non-febrile  course. 

Subnormal  temperatures  are  frequently  observed  in  melancholia, 
stuporous  states,  general  paresis,  idiocy,  and  occasionally  in  conditions 
of  great  excitement.  In  these  last  they  are  apt  to  indicate  approaching 
collapse. 

Hypernormal  temperatures  are  found  in  many  psychoses,  sometimes 
from  very  slight  peripheral  irritations,  such  as  retention  of  urine, 
gastric  catarrh,  constipation,  mild  bronchitis,  decubitus,  sometimes  from 
organic  changes  in  thermogenic  centers.  Hysterical  complications  may 
be  associated  with  hysterical  fever.  Motor  agitation  in  mania,  acute 
paranoia,  melancholia,  and  so  on,  may,  if  marked,  give  rise  to  febrile 
symptoms.  The  status  epilepticus  and  convulsive  seizures  of  general 
paresis  increase  the  temperature,  as  a  rule,  to  a  noteworthy  degree. 
Many  writers  have  described  diurnal  oscillations  of  temperature,  varia- 
tions from  day  to  day,  asymmetrical  axillary  temperature,  and  general 
subnormal  and  hypernormal  conditions  of  temperature  in  paralytic 
dementia ;  and  some  years  ago,  in  association  with  Dr.  Langdon,  I 
undertook  a  verification  of  these  statements  at  the  Hudson  River  State 
Hospital  for  the  Insane.  ^  These  are  the  conclusions  we  drew  from  a 
study  of  the  temperature  in  twenty-five  cases  of  general  paresis  : 

1.  As  regards  the  average  bodily  temperature,  we  find  it  to  corre- 
spond to  physiological  norms.  The  statements  of  our  predecessors  as 
to  hyperpyrexic  or  subnormal  averages  can  not  be  sustained. 

^  "  A  Study  of  the  Temperature  in  Twenty-five  Cases  of  General  Paralysis  of  the 
Insane,"  "Journal  of  Nervous  and  Mental  Diseases,"  Nov.,  1893. 

48 


754  MENTAL  DISEASES. 

2.  The  diurnal  oscillations  of  temperature  in  paretics  also  corre- 
spond to  physiological  norms.  The  statements  to  be  found  in  literature 
as  to  extraordinary  daily  variations  being  frequent  in  these  cases  are 
absolutely  erroneous. 

3.  Asymmetrical  axillary  differences  are  so  small  that  they  can  not 
be  considered  as  abnormal,  and  certainly  not  of  any  diagnostic  sig- 
nificance. 

4.  When  unusual  variations  of  temperature  occur  in  general  paretics, 
their  cause  must  be  sought  for  in  conditions  not  related  to  the  patho- 
logical phenomena  of  paralytic  dementia,  but  depending  upon  thermo- 
genic features  unrecognized  by  the  physician,  or  "masked"  by  the 
mental  state  of  the  patient.  Thus,  in  case  two  of  our  series,  an  in- 
creasing hyperpyrexia  was  noted  during  the  second  week's  observations, 
but  the  pneumonia  causing  it  was  "  masked "  until  the  fifth  or  sixth 
day,  the  patient  dying  on  the  sixth  day.  Again,  in  case  ten,  where  the 
highest  single  daily  oscillation  was  3.4  degrees,  and  the  average  daily 
oscillation  for  the  week  2.2  degrees,  the  patient  suffered  from  bed-sores, 
which  undoubtedly  produced  some  septicemia.  That  variations  of  tem- 
perature take  place  in  connection  with  the  paralytic  and  convulsive 
seizures  of  these  cases  we  do  not  gainsay. 

Vascular  Disorders. — The  action  of  the  heart  and  vessels  is  often 
influenced  by  insanity.  The  pulse  is  subject  to  acceleration  in  excited 
and  neurasthenic  states,  and  to  retardation  in  stuporous  conditions. 
Variations  in  arterial  tension  are  particularly  noticeable  at  times ; 
arterial  spasm  in  any  psychosis,  but  especially  in  melancholia,  de- 
pressed types  of  general  paresis,  and  in  paranoia  ;  arterial  paralysis  as 
a  sequel  to  this.  No  doubt  strong  mental  shocks  and  depressive  or 
exalting  affects  are  associated  with  anomalies  of  the  vasomotor  innerva- 
tion. Perhaps  many  psychoses  depend  upon  cerebral  angioneuroses. 
The  apoplectiform,  epileptiform,  and  maniacal  seizures  of  general 
paresis  are  believed  to  have  their  origin  in  these.  Precordial  anxiety, 
the  neuropathic  cervical  globus,  and  other  paresthetic  and  paralgesia 
sensations  in  the  domain  of  the  vagus,  are  also,  in  all  likelihood,  due 
to  angioneurotic  conditions. 


CHAPTER  IV. 

EXAMINATION  OF  THE  PATIENT;  DIAGNOSIS;  COURSE 
OF  THE  DISEASE;  PROGNOSIS. 

In  most  cases  of  insanity  the  diagnosis  of  the  presence  of  a  psy- 
chosis and  also  of  the  form  is  by  no  means  difficult ;  but  there  are 
many  in  which  this  is  not  the  case.  Medicolegal  cases  especially  re- 
quire most  careful  and  painstaking  investigation  in  order  to  arrive  at 
exact  knowledge  of   their  mental  state.     It  is  well  to   follow  at  all 


EXAJHNATIOX  OF  THE  PATIENT.  755 

times  some  fixed   sclieme  of  examination,  and  the  writer  advises  the 
following  : 

1.  Hereditary  factors. 

2.  Pregnancy  and  partnrition  of  mother. 

3.  Convulsions  or  other  nervous  disorders  in  infancy. 

4.  At  what  age  did  patient  walk,  speak,  and  complete  dentition  ? 

5.  Degree  and  character  of  education. 

6.  Rachitis  or  febrile  disease  in  childhood. 

7.  Character  and  temperament  in  childhood. 

8.  Period  of  puljerty — Was  its  development  normal  ? 

9.  Strength  of  sexual  instinct  at  this  period  ?     Masturbation  ? 

10.  Occupation  during  adolescence. 

11.  Character,  temperament,   religion,  physical  condition,  diseases 
during  adolescence. 

12.  Sexual  relations — excessive,  illicit  ;  marriage — venereal  disease, 
puerperium. 

13.  Intemperance  in  the  use  of  alcohol  or  drugs,  overwork,  shock, 
trauma  to  the  head,  infectious  diseases,  genital  disorders. 

14.  Psycopathic  constitution,  previous  attacks. 

15.  History  of  present  attack. 

16.  Probable  etiology. 

Physical    Condition. — 1.  Height,    weight,   nutrition,   circulation, 
pulse,  temperature. 

2.  Cranial  measurements.  1  o        i      ^  r:^^-  ^ 

o    o^-        ^      r.  1  ,  •  y  See  chapter  on  JLtiology. 

3.  Stigmata  oi  degeneration,     j  ^  ^-^ 

4.  Condition  of  heart,  lungs,  alimentary  canal,  genito-urinary 
organs. 

5.  Reflexes,  pupillary  and  tendon. 

6.  Condition  of  cranial  nerves. 

7.  Motor  symptoms — paralysis  or  morbid  movement,  gait. 

8.  Common  sensory  symptoms — paresthesia,  hyperesthesia,  an- 
esthesia. 

9.  Special  sensory  symptoms — sight,  hearing,  smell,  taste,  field  of 
vision. 

10.  Speech    disorders — stammering,    syllabic    articulation,    paretic 
speech,  motor  or  sensory  aphasia,  agraphia,  apraxia,  verbigeration. 

11.  Sleep. 

12.  Expression,  gesticulation,  attitude. 

Psychic  Condition. — 1.  Mode   of  speech — accelerated,  retarded, 
mute,  incoherent. 

2.  Conduct — Does  patient  care  for  his  person  and  dress  ?  Does 
he  attend  to  his  ordinary  duties  ?  Is  he  excited  and  active,  or  depressed 
and  c^uiet  ? 

3.  Illusions  or  hallucinations  ? 

4.  Mood — Is  the  fundamental  mood  depressed,  exalted,  irritable, 
changeable,  apathetic  ? 

5.  Ethical  feelings — What  is  the  state  of  his  moral  conceptions  and 
judgments  ? 

6.  Attention — Does  the  patient  note  what  goes  on  about  him,  etc.  ? 


756  MENTAL  DISEASES. 

7.  Memory — Weakened  or  increased  as  regards  long  past  and  recent 
events.  Test  mathematical,  geographical,  and  historical  knowledge. 
Test  dates,  ages  and  names  of  members  of  family^  the  events  of  the 
past  few  days,  etc. 

8.  Idea-association — Is  there  apraxia  or  parapraxia?  Does  the 
patient  orient  himself  as  to  place,  time,  and  objects  and  persons  about 
him  ?     Is  the  flow  of  ideas  accelerated,  retarded,  or  incoherent  ? 

9.  Judgment — How  does  he  explain  his  own  morbid  condition  and 
his  relation  to  his  surroundings  ?  What  does  he  busy  himself  with  now, 
and  what  are  his  plans  and  purposes  for  the  future  ? 

10.  Delusions  and  imperative  ideas. 

From  the  scheme  just  given,  it  will  be  seen  that  the  study  of  a 
case  of  insanity,  and  the  taking  of  the  history  of  the  antecedent  fac- 
tors and  of  the  psychic  disorder  itself,  involve  much  more  elaborate 
attention  than  is  the  case  with  the  ordinary  physical  diseases  which  one 
meets  with  in  practice.  In  medicolegal  cases  we  have  to  guard  against 
several  sources  of  error  in  our  diagnosis,  among  which  are  the  conceal- 
ment of  delusions  by  an  actually  insane  patient  and  the  simulation  of 
insanity  by  a  sane  criminal.  The  forms  of  insanity  usually  simulated, 
because  of  the  facility  of  so  doing,  are  a  maniacal  state,  dementia  or 
stuporous  melancholia,  and  epilepsy  with  insanity.  Only  one  with 
excellent  knowledge  of  the  symptoms  of  insanitA^  can  simulate  any 
form  of  psychic  disorder  so  well  as  to  defy  the  skill  of  the  physician 
familiar  with  mental  diseases. 

In  general  practice  it  sometimes  occurs  that  peculiar  forms  of  de- 
lirium incident  to  severe  visceral  disease  may  be  at  first  mistaken  for 
insanity.  Thus  I  have,  on  a  number  of  occasions,  been  called  upon  to 
assist  in  the  commitment  of  patients  to  asylums,  where  careful  examina- 
tion showed  the  existence  of  either  a  transitory  delirium  in  association 
with  an  apoplectiform  or  other  organic  lesion  of  the  brain,  or  a  de- 
lirium from  some  such  visceral  condition  as  Bright's  disease.  Delirium 
of  this  kind  is  distinguished,  first,  by  the  discovery  of  the  associated 
and  causative  organic  disease,  and,  secondly,  by  the  usual  non-conformity 
of  the  delirium  to  any  special  type  of  psychosis. 

Were  I  to  formulate  a  series  of  rules  to  guide  the  examiner  in  his 
investigation  of  the  mental  condition  of  a  patient,  they  would  be  some- 
what as  follows ;  yet  it  is  to  be  remembered  that  these  are  not  fixed 
rules,  but  subject  to  much  modification  by  the  tact,  good  judgment,  and 
common  sense  of  the  examiner : 

1.  It  is  to  be  presumed  that  previous  to  seeing  the  patient  the 
examiner  has  fully  informed  himself  of  all  of  the  facts  to  be  famished 
by  relatives  or  friends,  and  has,  when  possible,  inspected  letters  and 
other  writings,  which  so  often  prove  fruitful  soui'ces  of  information. 

2.  Go  to  the  patient  as  a  physician,  and  not  under  the  pretense  of  being 
something  else — a  device  so  often  suggested  by  the  family  and  friends. 

3.  Proceed  to  the  physical  examination  of  the  patient,  during  which 
tactful  questioning  will  determine  the  direction  to  follow  in  further 
inquiries. 

4.  Gain  the  good  will  of  the  patient  by  kindness  and  consideration. 


COURSE  OF  INSANITY.  757 

5.  Even  if  the  patient  is  distrnstful  and  nncommnnicative,  be  politely 
persistent,  and  prolong  the  Hrst  examination,  even  to  the  extent  of  trying 
the  patient,  nntil  the  object  is  attained  ;  for  many  patients  will,  when 
fatigued,  finally  yield  to  the  friendly  insistence  of  the  examiner. 

6.  If  one  examination  is  insufficient,  however,  have  as  many  inter- 
views as  are  requisite  for  the  purpose  in  view — a  careful  scientific  diag- 
nosis.     In  medicolegal  investigations  this  is  especially  necessary. 

Course  of  Insanity. — In  all  forms  of  insanity  we  should  seek  to 
divide  the  symptoms  presented  into  primary  and  secondary  classes,  not 
only  because  of  the  interest  of  so  doing,  but  because  of  the  value  of 
the  division  in  the  matter  of  diagnosis.  For  instance,  in  some  cases  we 
discover  hallucinations  and  illusions  to  be  the  primary  symptoms,  and, 
in  addition  to  these,  we  observe,  as  secondary  symptoms,  delusions, 
diminished  attention,  inhibition  of  thought,  motor  inhibition,  and  an 
anxious  state  ;  the  condition  is  that  of  hallucinatory  stupor. 

Furthermore,  we  will  divide  insanities  into  acute  and  chronic  forms, 
referring  usually  rather  to  the  rapid  or  slow  mode  of  onset  than  to  the 
duration  of  the  disease.  But  sometimes  these  qualifications  are  em- 
ployed in  connection  with  the  duration  of  the  insanity.  Thus,  it  is 
customary  in  some  asylums  to  designate  mania  or  melancholia  as  acute 
for  one  year,  at  the  expiration  of  which  the  term  chronic  is  used.  Re- 
missions in  insanity  are  periods  of  improvement  or  apparent  recovery. 
Intermissions,  or  lucid  intervals,  are  periods  of  complete  recovery  be- 
tween attacks. 

Mental  disorders,  owing  to  the  delicate  nature  of  the  physical  struc- 
tures in  which  morbid  changes  take  place,  are  prone  to  run  a  longer 
course  than  diseases  of  other  than  nervous  tissues.  It  is  true  that  tran- 
sitory insanity  and  acute  delirium  may  complete  their  course  in  a  few 
days,  and  that  acute  mania  or  melancholia  may  recover  in  a  month. 
But  three  to  six  months  is  a  better  average  for  acute  mania  and  mel- 
ancholia. Chronic  insanities  may  last  indefinitely,  for,  strangely 
enough,  there  seems  to  be  little  in  these  slow  alterations  of  the  mind  to 
influence  vitality.  The  average  life  of  chronic  lunatics  in  asylums  is 
said  to  be  some  thirteen  years,  to  which,  no  doubt,  the  regularity  of  life 
in  institutions  contributes.  Many  cases  of  marked  chronic  insanity  last 
twenty,  thirty,  even  fifty,  years,  and  over. 

In  any  given  case  of  curable  insanity,  we  usually  discover,  on  ex- 
amination, certain  stages  of  evolution,  prodromata,  complete  develop- 
ment, and  involution  or  convalescence.  Regis  has  devised  charts  which 
show  diagram matically  the  daily  range  of  aifects  in  cases  of  acute  mania, 
acute  melancholiji,  and  circular  insanity.  In  acute  mania,  for  instance, 
we  note  a  brief  prodromal  stage  of  depression,  followed  by  gradually  in- 
creasing maniacal  excitement,  then  by  gradual  subsidence  of  the  exalted 
stage  to  the  normal  line.  He  should  have  added  before  the  normal  ter- 
mination an  aftermath  of  a  peculiar  tearful  irritability  noticeable  in  these 
cases.  An  analogous  reactive  condition  is  observed  near  the  termina- 
tion of  acute  melancholia  in  recovery — a  certain  morbid  cheerfidness. 

Insanity  terminates  in  recovery,  in  recovery  with  defect,  in  chronic 
persistence  of  the  same  symptoms  as  at  first  manifested,  in  secondary  or 


758  MENTAL   DISEASES. 

terminal  dementia,  or  in  death.  Death  often  arises  from  exhaustion  due 
to  ideomotor  excitement,  and  in  organic  psychoses  from  associated  dis- 
ease of  the  central  nervous  system,  but,  as  a  rule,  death  in  insanity  is 
not  a  consequence  of  the  mental  disorder,  but  of  intercurrent  or  inci- 
dental disease,  such  as  pneumonia,  tuberculosis,  etc.  There  is  great 
variation  as  regards  curability  in  the  different  tyjDes  of  psychoses.  For 
instance,  ninet}"  per  cent,  of  cases  of  simple  melancholia  and  seventy-  per 
cent,  of  acute  mania  recover,  while  general  paresis  is  invariably  fatal. 

Prognosis, — The  prognosis  Avill  depend  upon  several  factors,  among 
which  the  most  important  are  the  t}'pe  of  insanity  presented,  the  course, 
the  character  of  certain  symptoms,  and  the  intellectual  development  of 
the  patient. 

As  regards  the  type  of  insanity  presented,  affective  insanities  (mania 
and  melancholia)  are  the  most  curable.  Systematized  chronic  insani- 
ties (paranoia)  and  cyclical  forms  rarely  recover.  Organic  insanities 
are  nearly  always  incurable,  if  not  fatal.  In  mania  and  melancholia, 
the  acuter  the  onset  and  the  more  rapid  and  intense  the  appearance  of 
the  symptoms,  the  better  the  prognosis.  Slow  development  and  prog- 
ress and  partial  remissions  are  unfavorable. 

The  etiology  has  considerable  influence  on  prognosis.  A  transitory- 
cause,  like  fright  or  anemia,  is  favorable.  The  older  the  patient,  the 
worse  the  prognosis.  Hereditary  taint  is  not  at  all  unfavorable  as 
regards  recovery  from  an  attack  of  acute  insanity-,  but  ver^^  much  so  as 
regards  the  probability  of  relapse.  On  the  other  hand,  a  hereditary- 
taint  in  insanity  of  slow  inception  is  of  serious  significance.  Alcohol 
and  morphin,  as  etiological  factors,  influence  prognosis  unfavorably, 
because  of  the  psychic  degeneration  they  superinduce.  S^iohilis  is  not 
unfavorable  if  the  insanit}^  is  due  to  direct  specific  disorders  of  the 
brain,  but  of  bad  import  if  due  to  the  later,  chronic,  difiuse,  specific 
alterations  in  the  central  nervous  system. 

Special  symptoms,  such  as  defect  in  the  intellectual  processes,  sys- 
tematization  of  delusions,  primaiy  delusions,  jDaralysis,  and  convulsions, 
are  significant  of  incurability. 

The  lower  the  gi-ade  of  intellectual  development  in  the  patient,  the 
greater  the  danger  of  termination  in  dementia. 


CHAPTER  V. 
GENERAL  TREATMENT  OF  INSANITY. 

It  is  not  so  long  a  time  since  the  insane  in  Cliristendriui  were  be- 
lieved to  be  possessed  of  devils  and  accursed.  On  the  other  hand,  in 
certain  parts  of  heathendom  (among  the  ]Mohammedansj  it  was  sup- 
posed that  the  souls  of  the  insane  had  been  removed  early  by  God  as  a 


GENERAL    TREATMENT  OF  INSANITY.  759 

special  mark  of  favor,  and  that  they  were,  tlierefore,  blessed.  Medieval 
treatment  was  founded  upon  the  curious  patholocry  just  described.  One 
portion  of  the  world  ducked,  whipped,  tortured,  chained  in  dungeons, 
and  occasionally  burned,  the  insane.  The  heathen  treated  their  insane, 
upon  the  whole,  comparatively  well. 

After  a  time,  many  of  the  therapeutic  measures  employed  by  the 
Europeans  of  the  middle  ages  were  abandoned  as  unsatisfactorv'.  But 
society  still  had  to  be  protected ;  so  the  insane  were  fettered  in  the  cells 
of  jails  and  fortresses  and  solitary  towers,  until  a  realizing  sense  of  the 
inhumanity  of  such  treatment  struck  a  responsive  chord  somewhere  in 
the  breast  of  a  Tuke,  a  Connolly,  a  Pinel,  a  Eush,  a  Kirkbride,  an 
Earle,  and  doubtless  other,  but  unknown,  immortals  both  before  and 
after  them. 

Insanity  thus  gradually  came  to  be  looked  upon  as  a  disease,  and 
not  a  penal  offense,  and,  instead  of  prisons,  special  buildings  were  set 
apart  for  the  particular  custody  of  the  insane.  The  great  object  of  the 
asylums  at  first  was  to  aflPord  protection  to  society  from  lunatics,  to  pro- 
tect them  from  themselves,  and  to  provide  for  their  care  and  support, 
when  at  pui)lic  cost,  in  an  economical  manner.  A  hundred  years  ago, 
however,  the  asylum  was  still  a  species  of  jail,  for  its  evolution  had  not 
yet  proceeded  far.  Dungeons  and  iron  chains  and  staples  in  stone 
walls  and  stone  floors  were  still  in  use  in  many  places.  Indeed,  it  is 
scarcely  over  eighty  years  since  Norris,  a  patient  in  Bedlam  (Bethlehem 
Hospital),  in  the  great  Christian  city  of  London,  was  kept  for  twelve 
years  in  a  cell,  with  an  iron  collar  riveted  around  his  neck  and  iron 
bands  and  rings  around  his  wrists,  arms,  and  ankles,  the  neck  being 
fastened  to  the  wall  and  the  leg  to  a  rude  box  of  filthy  straw. 

Asylums  have,  at  the  present  time,  come  to  be  recognized  as  hos- 
pitals, and  they  are  approaching  nearer  to  that  ideal  every  year. 
Occasionally,  one  finds  among  them  some  rudimentar}"  appendage  which 
is  reminiscent  of  the  embryonal  stage  of  their  evolution ;  but  this  is, 
fortunately,  rare.  The  well-conducted  hos^oital  for  the  insane,  to-day, 
is  different  from  the  asylum  of  years  ago  ;  the  depressing,  barren  halls 
and  wards  and  naked  floors  have  given  place  to  pleasantly  furnished 
and  carpeted,  cheerful-looking  parlors,  sitting-rooms,  and  bed-rooms  ; 
muffs  and  strait-jackets  have  disappeared ;  the  unintelligent  attendant 
has,  in  many  instances,  given  place  to  the  trained  nurse  ;  every  new 
means  of  treatment  is  carried  out  to  the  best  of  the  abilit}'  of  the 
asylum  physicians  ;  schools,  employment,  theatricals,  music,  and  out- 
of-door  walks  are  provided  in  the  place  of  the  old,  deadly  monotony, 
and,  in  fact,  the  asylum  has  gradually  undergone  a  metamorphosis, 
until  its  charactel"  has  completely  changed.  There  are,  to  be  sure,  not 
many  perfectly  ideal  institutions  as  yet  in  existence,  but  there  are  some 
which  approach  very  nearly  to  it,  as,  for  instance,  that  at  Alt-Scherbitz, 
near  Leipzig,  and  the  new  asylum  at  Rome,  both  of  which  I  visited 
and  described  in  1887.^  These  are,  of  course,  constructed  on  the  cot- 
tage and  pavilion  plan,  so  arranged  as  to  impress  one  as  small  colonies 

^  '"Some  European  Asylums,"  "  Amer.  Jour.  Insanity,"  July,  1887. 


760  MENTAL  DISEASES. 

or  villages,  with  separate  buildings  for  those  merely  there  for  custody 
because  of  dangerous  propensities,  those  brought  there  to  be  cared  for 
kindly  during  the  remainder  of  their  useless  lives,  those  who  carry  on. 
various  occupations,  and,  finally,  for  such  as  enter  particularly  to  secure 
treatment  for  the  brain-malady  which  has  bereft  them  temporarily  of 
their  reason.  The  colony  system  of  caring  for  the  dependent  classes — 
which  the  writer  thinks  should  ultimately  be  adopted  for  all  kinds  of 
defectives — is  well  exemplified  by  the  Craig  Colony  for  epileptics  in  the 
State  of  New  York. 

I  will  say  that  I  believe  improvement  and  reform  are  constantly 
going  on  in  asylums  throughout  the  world  ;  that  no  one  is  more  anxious 
than  are  their  superintendents  to  make  progress  in  the  care  and  manage- 
ment of  the  insane.  They  are  rapidly  reaching  the  best  methods  of 
dealing  with  the  insane  poor.  If  any  are  tardy  in  this  advance,  it  is 
because  they  are  so  often  hampered  by  the  never-ending  overcrowding 
of  our  public  asylums,  by  the  interference  of  politics,  by  the  lack  of 
money,  by  the  want  of  a  sufficient  number  of  medical  assistants,  and  by 
a  multiplicity  of  official  duties. 

While  these  statements  are  undoubtedly  true, — and  great  credit  is  due 
the  asylum  physicians  of  the  present  day  for  their  strenuous  efforts  in 
behalf  of  their  charges, — I  believe  that  the  ideal  treatment  of  almost  any 
insane  person  is  to  be  sought  outside  of  an  asylum.  After  an  asylum 
experience  of  some  years,  and  an  experience  of  many  years,  too,  in 
private  practice,  I  feel  that  I  am  in  a  position  to  judge  fairly  well  of 
the  relative  merits  of  treatment  in  and  out  of  asylums. 

Theoretically,  it  ought  to  be  the  right  of  every  individual  in  sickness 
to  receive  the  best  treatment  that  medical  science  affords  ;  but  this  right 
can  be  enjoyed  by  very  few.  There  are  too  many  interfering  condi- 
tions. Not  every  injured  man  is  within  reach  of  the  best  surgeon  ;  not 
every  fever-stricken  one  convenient  to  the  best  physician ;  and  few  are 
the  deaf,  the  blind,  the  lame,  those  with  crippled  bodies  and  those  with 
disordered  minds,  who  ever  really  receive  the  best  treatment  that  the 
world  can  give.  The  intelligent  doctor  and  the  scientific  skill  are  not 
the  only  requisites.  Other  conditions  are  good  nursing,  the  most  suit- 
able climate,  the  best  hygienic  surroundings,  the  best  moral  atmosphere. 
In  dealing  with  affections  of  the  body  solely,  there  is  often  much  to  be 
desired  ;  but  it  is  particularly  in  the  treatment  of  those  who  are  men- 
tally as  well  as  physically  afflicted  that  so  much  which  should  be  done 
is  left  undone.  The  obstacles  in  the  way  of  securing  the  best  treatment 
are  multiplied  in  the  case  of  the  insane  by  the  dethronement  of  the 
supreme  centers  of  psychic  function. 

Just  as  a  hospital  is  a  better  place  than  a  tenement  house  for  a  sur- 
gical patient  or  a  case  of  fever,  so  is  the  asylum  superior  to  the  home 
in  the  caretaking  of  the  pauper  and  indigent  lunatic.  The  acutely 
insane  of  the  poorer  classes  are  best  treated,  at  present,  in  our  large 
public  institutions  ;  and  those  among  the  moderately  well-to-do,  either  at 
home  or  in  the  small  private  asylums.  Only  the  insane  of  the  wealthy 
classes  can,  perhaps,  enjoy  and  carry  out  ideal  methods  of  treatment  in. 
their  own  homes,  in  country  houses,  or  in  foreign  travel. 


GENERAL    TREATMENT  OF  INSANITY.  761 

It  is,  of  course,  needless  to  say  that  there  are  many  degrees  of 
insanity  ;  that  there  are  hundreds  of  cases  tluit  are  never  obhged  to  go 
to  an  asylum  at  all ;  that  in  society  are  many  insane  })ersons  carrying  on 
legitimate  occupations  and  caring  for  themselves  and  families  ;  and  that, 
on  the  other  hand,  there  are  cases  for  which  nothing  but  connnitment 
to  an  asylum  would  be  suitable  or  feasible.  But  we  should  not  send 
any  patient  to  an  asylum  unless  he  needs  restraint  because  of  danger 
to  himself  or  others,  or  because  proper  treatment  and  supervision  are 
difficult  in  his  home,  owing  generally  to  poverty  or  other  insurmountable 
conditions.  The  sooner  a  case  of  acute  insanity  occurring  in  a  pau})er 
or  an  indigent  is  removed  to  an  asylum,  the  better  are  his  chances  for 
recovery.  This  merely  signifies  that  the  earlier  treatment  is  undertaken 
by  those  who  are  familiar  with  the  management  and  care  of  the  insane, 
the  better  for  the  patient.  Early  treatment  by  physicians  of  experience 
in  psychiatry  is  demanded.  At  present  this  end  is  best  attained  by 
resort  to  the  asylums  of  the  neighborhood.  But  the  writer  has  often 
called  attention  to  the  need  of  increasing  and  extending  the  facilities 
for  the  early  treatment  of  the  insane — a  matter  which  can  be  accom- 
plished in  several  ways.        The  lines  of  progress  in  such  direction  are  : 

(1)  The  opening  of  special  reception- wards  or  pavilions  for  the 
insane  in  general  hospitals  ;  (2)  the  establishment  of  psychopathic  hos- 
pitals in  large  cities ;  (3)  the  creation  of  outdoor  departments  in  con- 
nection with  asylums  situated  in  densely  populous  districts. 

Before  taking  up  the  matter  of  the  treatment  of  insanity,  a  few 
words  should  be  said  as  regards 

Prophylaxis. — Naturally,  the  question  of  the  proper  care  and  edu- 
cation of  children  with  a  tainted  line  or  lines  of  ancestry  often  comes 
before  the  physician.  Much  can  be  done  to  ward  oif  impending  future 
evils  by  due  and  early  attention  to  the  mental  and  physical  evolution 
of  such  children.  One  can  not  begin  too  soon  to  regulate  the  life  of 
these  little  ones.  The  very  milk  of  a  weak  and  anemic  mother  may 
diminish  the  feeble  resistance  of  a  degenerate  child.  From  the  day  of 
birth  the  prophylaxis  must  begin.  The  points  to  be  observed  in  the 
eifort  to  accomplish  this  are  as  follows  : 

1.  Cultivate  the  body  of  the  growing  child.  Develop  him  physi- 
cally by  careful  and  regular  diet,  regular  hours  of  sleep,  outdoor  life, 
efficient  systems  of  exercise. 

2.  Let  his  training  be  muscular  rather  than  intellectual,  manual 
training  rather  than  lessons,  especially  in  the  early  years  of  childhood. 
No  schools  until  the  age  of  seven  or  eight  vears. 

3.  The  child  with  degenerate  tendencies  should  be  forbidden  all 
nervous  stimulanfs,  such  as  tea,  coffee,  wines,  beer,  tobacco. 

4.  Seek  to  develop  the  resistance  of  the  organism  to  all  external 
stimuli,  hardening  his  body  by  the  daily  morning  cold  bath,  frictions, 
exercise,  a  hard  bed,  a  cold  sleeping-room ;  accustoming  his  mind  to 
the  courageous  endurances  of  pain  and  mental  stresses, 

5.  Guard  well  the  epoch  of  puberty. 

6.  Let  the  occupation  chosen  for  later  years    be  also  one  for  the 


762  MENTAL   DISEASES. 

muscles  rather  than  for  the   mind,  an  outdoor  rather  than  an  indoor 
calling,  a  country  rather  than  a  city  life. 

Isolation. — On  being  called  to  see  a  patient  suffering  from  insanity, 
the  first  point  which  arises  is  whether  he  should  be  sent  to  an  asylum 
or  not.  This  is  generally  a  question  of  means.  Isolation  from  the  imme- 
diate friends  is  in  nearly  every  case  a  requisite.  If  the  patient  belongs 
to  the  indigent  or  to  the  middle  classes,  isolation  and  the  best  treat- 
ment for  his  malady  are  only  to  be  satisfactorily  obtained  in  an  asylum 
or  hospital  for  the  insane.  Among  the  well-to-do,  the  needed  isolation 
may  be  successfully  secured  in  his  own  house,  in  an  ordinary  sanatorium, 
or  by  means  of  travel  with  a  suitable  nurse,  companion,  or  physician. 
The  kind  of  treatment  best  adapted  to  the  nature  of  the  case  must  be 
decided  by  the  physician.  The  quiet  of  a  private  house  in  the  city  or 
country  is  best  for  some  cases,  while  the  tonic  and  stimulus  of  foreign 
travel  are  indicated  in  others.  It  may  be  stated  that,  when  travel  seems 
to  be  the  prescription  required,  the  greater  the  change  from  the  envi- 
ronment in  which  the  mental  disorder  developed,  the  better.  The 
cities  of  Great  Britain  and  the  Continent  do  not  differ  essentially  from 
our  own  cities,  and  patients  should  not  be  sent  to  such  places  with  the 
idea  of  securing  a  change  of  environment.  Norway  in  summer,  Egypt 
in  winter,  and  Mexico  in  either  summer  or  winter,  are  regions  which 
offer  the  greatest  inducements  in  the  way  of  tonics  to  the  nervous 
system  and  stimulus  to  the  mind,  and  all  three  are,  at  the  same  time, 
peculiarly  restful  and  calmative. 

If  these  methods  of  home,  country  house,  or  travel  are  for  any 
reason  impracticable,  then  the  smallest  private  asylum  that  can  be  found 
is  to  be  selected,  for  the  fewer  other  insane  jDersons  and  the  greater  num- 
ber of  sane  persons  the  patient  comes  in  contact  with,  the  better  will  be 
his  chances  for  recovery.  There  is  a  need  for  physicians  in  practice  in 
the  country  who  will  be  duly  authorized  and  empowered  by  law  to 
receive  in  their  own  homes  and  care  for  one  such  patient.  The  chief 
drawback  in  home-treatment,  if  long  continued,  is  usually  the  bad  effect 
of  association  with  an  insane  person  upon  other  members  of  his  family, 
particularly  if  they  be  neuropathic.  With  a  sufficiency  of  nurses  and 
room,  there  is  no  contingency  in  the  treatment  of  the  insane  that  can 
not  be  guarded  against.  These  being  provided,  the  worst  features  in  a 
case,  such  as  violence,  homicidal  and  suicidal  tendencies,  attemjjts  at 
self-mutilation,  etc.,  may  be  as  well  avoided  outside  as  inside  of  an 
asylum.  There  are  cases  in  which — though  I  am  opposed  to  mechanical 
restraint  in  great  measure — I  should  employ  long-sleeved  night-gowns, 
or  even  camisoles,  rather  than  let  them  go  from  home  before  all  means 
of  cure  had  been  tried  at  least  for  a  few  weeks'  time. 

The  conditions  and  propensities  that  we  have  to  combat  are  many. 
The  choice  of  method  must  be  the  result  of  careful  deliberation,  and  after 
judicial  survey  of  all  the  features  presented.  We  usually  need  the 
assistance  of  skilled  and  experienced  nurses.  Thanks  to  the  asylum 
training-schools,  there  are  numbers  of  such  trained  nurses  of  both  sexes 
to  be  had  in  our  large  cities. 


GENERAL   TREATMENT  OF  INSANITY.  763 


TREATMENT  OF  ACUTE  CASES. 

In  acute  cases,  whether  of  mania  or  melancholia,  it  has  been  my 
experience  that  confinement  to  bed  is  a  valuable  factor  in  cure.  Hence, 
on  being  called  to  such  a  case,  I  have  the  patient  put  to  bed.  Due 
precautions  are  taken  as  to  the  removal  of  all  sharp  instruments, 
weapons,  drugs,  cords,  door-keys,  and  the  like,  and  by  a  simple  device 
the  windows  so  arranged  that  they  may  not  be  opened  beyond  six 
inches ;  otherwise  the  furnishings  may  be  left  as  they  are  without 
attention. 

Insomnia  and  mental  and  motor  excitement  most  frequently  demand 
our  best  skill.  In  emergency,  I  am  in  the  habit  of  using  duboisin 
sulphate  hypodermatically  in  the  dose  of  y^-g-  of  a  grain,  or  sometimes 
hyoscyamin,  or  hyoscin  hydrobromate  in  doses  of  from  -^^-^  to  -^-^  of  a 
grain  hypodermatically,  though  these  latter  are  not  so  satisfactory  as 
duboisin.  But  for  routine  treatment  of  insomnia  and  maniacal  excite- 
ment I  much  prefer  hydrotherapy  to  drugs.  In  some  cases  the  pro- 
longed warm  bath  (70°— 90°  F.)  for  from  one-half  to  two  hours  may  be 
used,  but  in  all  cases  the  hot  wet-pack  is  applicable.  Sometimes  when 
the  wet-pack  does  not  suffice  to  quiet  fierce  maniacal  excitement,  I  use 
duboisin  in  addition,  or  give  doses  by  the  mouth  of  paraldehyd,  trional, 
and  sulphonal,  all  of  which  are  valuable  hypnotics. 

In  acute  depressed  conditions,  on  the  other  hand,  opiates  usually  act 
best  in  cases  in  which  hydrotherapy  does  not  subdue  the  insomnia,  dis- 
tress of  mind,  and  disordered  nervous  system.  Among  opiates,  codein 
seems  to  offer  advantages  over  others,  and  the  contraction  of  a  habit 
need  not  be  feared.  The  aqueous  extract  of  opium  or  morphin  may 
be  given  hypodermatically. 

The  refusal  of  food  is  another  element  of  danger.  Acute  insanity, 
besides  rest  in  bed,  quiet,  and  repose,  needs  overfeeding  to  balance  the 
great  waste  of  tissue  going  on  in  the  system.  While  many  cases  of 
acute  mania  will  eat  and  drink  ravenously  at  times,  from  the  nature  of 
things  their  actions  are  uncertain,  and  the  nurse  should  be  instructed 
to  feed  the  patient  almost  hourly  and  keep  account  of  what  is  given. 
Milk,  raw  eggs,  meat-juice,  and  occasional  stimulants  must,  in  extreme 
cases,  be  our  chief  reliance.  Having  an  intelligent  and  assiduous  nurse 
at  hand,  the  necessity  of  feeding  with  a  tube  will  only  rarely  occur. 
When  required,  the  soft  rubber  stomach-tube  may  be  introduced  by  the 
physician  through  the  mouth  or  nose,  a  funnel  attached,  and  the  liquid 
mixture  of  the  substances  named  allowed  to  flow  in. 

There  are  cases  (some  of  the  insanities  of  puberty  and  adolescence, 
and  other  forms)  in  which  anaphrodisiacs  modify  distinctly  the  trend  of 
delusions.  There  are  cases  in  which  intestinal  antiseptics  achieve  note- 
worthy results  ;  indeed,  the  instances  are  few  in  which  attention  to 
morbid  states  of  the  alimentary  canal  is  not  rewarded  by  considerable 
benefit  to  the  mental  condition  of  the  patient.  Arguments  with  patients 
upon  delusions,  more  or  less  fixed  in  character,  often  has,  despite  the 
opinions  of  numerous  alienists  to  the  contrary,  decided  value  in  altering 


764  MENTAL   DISEASES. 

their  beliefs,  and  at  times  even  eradicating  their  insane  ideas  altogether. 
It  is  true  that  occasional  argument  is  generally  of  no  avail.  Such  moral 
treatment  must  be  sedulously  and  perseveringly  employed,  daily  and  for 
weeks  or  months,  to  insure  success.  Argument  is  a  species  of  sugges- 
tion. The  tactful  and  judicious  physician  will  not  make  use  of  it  in 
cases  where  it  leads  to  irritation  and  would  seem  to  be  injurious. 

The  most  important  remedial  agents  employed  in  insanity  are  as 
follows  : 

The  Rest-cure. — This  has  already  been  briefly  referred  to.  It  was 
in  1860  that  Hilton  began  his  series  of  lectures  on  rest  and  pain,  in 
which  he  pointed  out  how  nmch  rest  had  to  do  with  growth  and  repair 
of  the  bodily  tissues,  and  fifteen  years  later  Mitchell  wrote  of  the  value 
of  rest  in  the  treatment  of  hysteria  and  neurasthenia.  Nowadays, 
however,  we  apply  the  principle  of  rest  to  a  great  variety  of  nervous 
disorders.  Besides  its  indication  in  many  cases  of  hysteria  and  neuras- 
thenia, we  find  it  of  the  greatest  benefit  in  all  sorts  of  nervous  and 
mental  troubles,  and  especially  in  such  as  evince  a  tendency  to  waste  of 
tissue  and  to  exhaustion. 

Most  cases  of  acute  mania  need  to  be  treated  by  rest,  which  should 
be  made  as  absolute  as  possible.  Many  cases  of  acute  melancholia 
recover  more  quickly  when  confined  to  bed.  While  in  many  mental 
cases  the  rest  should  be  absolute  for  a  period  of  several  weeks  in  order 
to  insure  a  successful  termination,  it  is  astonishing  how  much  benefit 
can  be  obtained  by  a  modified  rest  treatment — that  is,  by  merely  pro- 
longing the  daily  amount  of  repose  in  bed.  The  principle  is  to  apply 
rest  methodically,  and  in  proportion  to  the  degree  of  nervous  exhaus- 
tion, strain,  or  irritation. 

When  rest  is  made  nearly  absolute,  it  is  necessary  that  tissue  meta- 
bolism should  be  encouraged  by  attention  to  the  amount  and  quality 
of  food,  and  especially  by  substitution  of  some  passive  artificial  exer- 
cise for  the  active  movements  upon  which  the  organism  has  hitherto 
depended.     This  is  accomplished  chiefly  by  massage. 

Massage. — Massage  was  a  favorite  remedy  and  luxury  in  ancient 
Roman  times,  when  it  figured  as  the  Aliptic  Art  ;i  so  that  it  is  not  at  all 
a  new  remedy,  but  its  vogue  in  recent  years  has  assumed  enormous  pro- 
portions, and  it  has  received  a  scientific  study  and  systematization  to 
which  the  ancients  were  strangers.  This  rubbing,  beating,  and  knead- 
ing of  the  trunk  and  limbs,  when  skilfully  done,  is  an  essential  adjunct 
to  the  absolute  rest  treatment.  It  is  invaluable  in  many  kinds  of  pain, 
and  it  often  surpasses  drugs  as  a  soother  of  irritation  and  an  inducer  of 
sleep. 

Diet. — It  is  needless  to  say  that  in  connection  with  a  form  of  rest 
treatment  simplicity  should  be  the  rule  as  regards  food.  The  selection 
should  be  made  from  the  point  of  view  of  easy  digestibility,  and  fore- 
most in  this  regard  stand  milk  and  its  various  preparations.  Where 
milk  can  not  be  taken  in  its  ordinary  form,  some  more  digestible  prepa- 
ration may  be  employed,  such  as  peptonized  milk,   koumiss,  matzoon,^ 

1  "The  Aliptic  Art:  a  Historical  Study,"  by  the  author,  "Phil.  Med.  News,"' 
Aug.  11,  1883. 


GENERAL    TREATMENT  OE  INSANITY.  765 

or  somal.  In  cases  im(ler<><)in^  a  rest  treatment  this  is  the  main  staple 
of  food,  and  it  should  be  given  frequently  and  in  considerable  quantity. 
Overfeeding  is  indeed  another  principle  in  the  treatment  of  any  of  the 
nervous  and  mental  diseases  in  which  exhaustion  is  a  feature.  Thus, 
absolute  rest  and  overfeeding  must  be  our  chief  reliance  in  acute  mania, 
and  in  severe  types  of  melancholia.  Many  cases  require  feeding  every 
hour  or  two  hours.  Raw  or  soft-boiled  eggs,  rare  or  raw  beef,  specially 
pre})ared  cereals,  and  sometimes  green  vegetables  and  fruits  may  be 
added  to  the  diet.  (By  specially  prepared  cereals  I  mean  simple  boiled 
rice,  stale  bread  in  the  form  of  toast,  or,  better,  bread  which  has  been 
twice  baked — Zwieback).  Stimulants  are  only  occasionally  indicated, 
and  then  especially  in  acute  maniacal  or  other  dangerously  exhausting 
conditions. 

A  somewhat  similar  form  of  diet  is  appropriate  for  mental  disturb- 
ances having  a  rheumatic  or  gouty  diathesis  as  a  basis.  The  same  diet 
is  essential  in  all  cases  of  insanity,  neurasthenia,  epilepsy,  and  so  on, 
which  seem  to  depend  upon  auto-intoxication  from  fermentative  or 
putrefactive  changes  in  the  intestinal  contents,  and  such  cases  we  find 
nowadays  to  be  not  at  all  infrequent. 

Hydrotherapy. — When  in  1893  I  wrote  a  paper  on  "  Hydrotherapy 
in  the  Treatment  of  Nervous  and  Mental  Diseases  "  ("  Amer.  Jour,  of 
the  Med.  Sciences,"  February,  1893),  there  was  really  no  place  in  the 
city  of  New  York  to  which  one  could  send  patients  and  have  his  own 
ideas  as  to  treatment  faithfully  carried  out ;  nor  did  I  know  of  a  single 
asylum  for  the  insane  in  this  country  installed  with  hydrotherapeutio 
apparatus,  such  as  I  had  seen  in  a  number  of  asylums  abroad,  even 
in  so  remote  a  country  as  Greece.  Now  I  could  name  many  public 
and  private  asylums  which  are  equipped  with  arrangements  for  this 
purpose. 

Water  affects  the  nervous  system  in  a  variety  of  ways. 

Cold  baths  increase  and  warm  baths  diminish  the  irritability  of  the 
brain  and  spinal  cord  in  a  reflex  manner  by  stimulating  the  sensory 
and  vasomotor  nerves  of  the  skin,  thus  influencing  the  cerebrospinal 
circulation. 

Short  cold  baths,  especially  when  combined  with  sprinkling,  shower- 
ing, or  rubbing,  are  powerfully  stimulating,  exhilarating,  and  tonic. 
Cold  baths  stimulate  peristalsis  and  the  visceral  reflexes  in  the  cord, 
and  increase  blood-pressure.  Prolonged  warm  baths,  steam  and  hot- 
air  baths,  and  the  hot  pack  are  relaxing,  fatiguing,  and  tend  to  induce 
sleep.  Warm  baths  diminish  arterial  tension  and  reduce  the  irritability 
of  individual  nerves  and  the  whole  nervous  system.  The  spinal  douche 
is  of  the  greatest  service  in  many  nervous  disorders,  because  of  its  re- 
markable tonic,  revulsive,  and  derivative  effects.  It  is  a  powerful 
mental  as  well  as  physical  stimulus.  By  means  of  various  nozzles  it  is 
ejected  in  the  form  of  a  strong  stream  up  and  down  the  back  of  the 
patient  for  a  few  seconds  only,  at  a  distance  of  some  ten  feet.  Patients 
with  good  reaction  do  not  need  any  special  preparation,  but  at  the 
beginning  it  is  well  to  have  the  patient  take  a  warm  bath  or  stay  a  few 
minutes  in   a  hot-air  box   previous  to  its   application.     At  the  first 


766  MENTAL  DISEASES. 

Stances  the  water  should  not  be  too  cold.  Later,  it  may  be  gradually- 
lowered  to  50  °  F.  It  should  be  taken  every  day,  when  possible.  Oc- 
casionally this  cold  spinal  douche  is  alternated  with  a  hot  douche  (the 
so-called  Scotch  douche).  This  is  an  exceedingly  successful  procedure 
in  many  cases  of  hysteria,  neurasthenia,  and  in  lethargic  and  hysterical 
forms  of  insanity,  where  there  are  sluggish  intellect,  great  depression, 
apathy,  stupor,  catalepsy,  etc.,  and  in  any  case  of  nervous  and  mental 
disease  where  anemia,  chlorosis,  or  gastric  trouble  exists. 

In  insomnia  there  is  no  other  remedy  so  generally  efficient  and  at 
the  same  time  so  imiocuous.  I  have  seen  it  successful  in  wake- 
fulness from  every  kind  of  cause,  and  in  cases  seemingly  intractable 
to  other  remedies.  There  are  two  hydriatic  procedures  for  the 
production  of  sleep.  One  is  the  prolonged  warm  wliole  bath,  at  a 
temperature  of  70°  to  90°  F.,  for  from  one-half  to  two  hours  just  before 
retiring.  This  is  indicated  in  mild  cases  of  insomnia.  But  the  hot 
wet-pack  is  more  effectual  and  more  widely  applicable  in  all  forms  of 
sleeplessness,  whether  in  nervous  or  insane  individuals.  It  is  applied 
in  this  way :  A  blanket,  nine  by  nine  feet,  is  spread  upon  the  patient's 
bed,  and  upon  this  a  sheet,  wrung  out  dry  after  dipping  in  hot  water,  is 
laid.  The  patient  lies  down  upon  this,  and  the  sheet  is  at  once  evenly 
arranged  about  and  pressed  around  the  whole  body,  with  the  exception 
of  the  head,  after  which  the  blanket  is  also  immediately  likewise  closely 
adjusted  to  every  part  of  the  patient's  body.  Other  dry  blankets  may 
now  be  added  as  seems  necessary.  The  patient  remains  in  this  an  hour 
or  longer ;  all  night,  if  asleep. 

I  know  of  no  better  treatment  of  acute  maniacal  conditions,  for 
instance,  than  rest  in  bed,  overfeeding,  the  hot  wet-pack,  and  the  occa- 
sional employment  of  some  sleep-producing  agent. 

Treatment  of  Auto-intoxication. — Researches  in  the  physiologi- 
cal chemistry  of  digestion,  as  well  as  observations  in  many  pathological 
conditions,  have  established  that  auto-intoxication  from  the  absorption 
of  poisonous  substances  generated  in  the  alimentary  canal  by  putre- 
factive and  fermentative  processes  is  not  only  a  real  thing,  but  a  fre- 
quent factor  in  the  etiology  of  a  number  of  nervous  disorders,  such  as 
headache,  neurasthenia,  hysteria,  neuralgia,  and  even  graver  maladies, 
like  epilepsy,  melancholia,  mania.  It  behooves  us,  therefore,  in  these 
diseases,  to  investigate  carefully  for  evidence  of  any  such  cause.  Peri- 
odical or  constant  attacks  of  gaseous  diarrhea  are  somewhat  indicative 
of  this  condition.  Frequently  the  condition  of  the  bowels  furnishes  no 
information  of  the  actual  state  of  affairs.  Recent  researches  tend  to 
show  that  an  excess  of  ethereal  sulphates  in  the  urine  (indican)  in 
connection  with  other  symptoms  is  a  good  index  of  auto-intoxication. 

When  auto-intoxication  is  suspected  as  the  causative  factor  in  any 
nervous  disorder,  it  is  essential  to  regulate  the  diet  in  the  manner 
already  mentioned,  and  there  are  at  our  disposition  a  number  of  intes- 
tinal antiseptics  which,  though  not  always  efficient,  are  yet  often  of 
very  great  benefit.  I  have  found,  in  my  own  practice,  that  beta- 
naphtol  is  one  of  the  best  intestinal  antiseptics.  I  give  it  in  capsules 
of  five  grains  each,  two  hours  after  eating,  with  water.    In  several  cases 


GENERAL    TREATMENT  OF  INSANITY.  767 

of  epilepsy  and  of  nielancholia  it  has  acted  exceedingly  well.  In  many 
cases  of  epilepsy  salicylate  of  soda  has  also  proved  itself  of  great  value. 
Salol,  too,  is  a  good  intestinal  antiseptic.  Sometimes  I  have  made 
excellent  use  of  peppermint  for  the  same  purpose.  I  think  the  abun- 
dant use  of  water  a  necessary  adjunct  in  the  treatment,  usually  advising 
the  drinking  of  hot  water  several  times  daily  on  an  empty  stomach,  and 
sometimes  adding  thereto  frequent  flushing  of  the  large  intestine  with 
warm  water. 

Electrotherapy. — General  faradization  with  a  current  sufficiently 
strong  to  contract  the  muscles  has  much  the  same  value  as  massage 
where  the  rest-cure  is  employed  ;  it  exercises  the  muscles  and  stimulates 
metabolism.  Over  and  above  this  it  has  a  tonic  effect.  Galvanism  is 
only  of  use  in  complicating  conditions,  such  as  neuralgias,  sciatica,  and 
the  like."  The  same  is  true  of  the  static  and  sinusoidal  currents. 
Electrization  of  the  head  for  the  purpose  of  influencing  illusions,  hal- 
lucinations, and  delusions  is  occasionally  of  service,  but  doubtless  its 
influence  is  almost  wholly  of  a  suggestive  nature.  However,  it  is  not 
to  be  interdicted  on  that  account,  for  suggestion  is  in  itself  a  valuable 
therapeutical  adjunct,  and  so  good  a  method  of  increasing  its  usefulness 
as  is  afforded  by  electricity  is  not  to  be  slighted.  Suggestion  is  a  species 
of  psychic  therapy. 

Drugs. — The  narcotics  are  of  great  importance  in  the  treatment  of 
insanity.     Among  these,  opium  and  its  alkaloids  easily  stand  first. 

Opium,  morphin,  codein,  all  have  a  hypnotic  effect,  but  their 
especial  value  lies  in  their  sedative  influence  upon  mental  hyperesthesia, 
anxious  states,  etc.;  in  their  contraction  of  the  blood-vessels,  and  in 
their  stimulation  of  the  nutrition  of  the  central  nervous  system.  The 
hypodermatic  use  is  best.  They  are  particularly  indicated  in  melan- 
cholia, acute  alcoholic  psychoses,  and  hallucinatory  paranoia,  very 
seldom  in  maniacal  states.  They  are  contraindicated  in  mo.st  maniacal 
conditions,  collapse,  fatty  heart,  uncompensated  valvular  disease,  and 
marasmus.  The  patient  should  not  know  the  name  of  the  drug  used. 
Opium  and  codein  are  preferable  always  to  morphin,  because  of  less 
danger  of  forming  a  habit.  The  doses  must  be  gradually  increased. 
The  constipation  at  first  present  during  the  administration  of  opiates 
disappears  later. 

Hyoscin,  hyoscyamin,  and  duboisin  are  isomeric  alkaloids,  and 
have  much  the  same  qualities  and  are  alike  in  their  effects  upon  the 
organism.  Xext  to  the  opiates  they  form  the  chief  drugs  of  the 
alienist's  armamentarium.  Their  great  value  lies  in  their  sedative 
influence  upon  motor  centers.  They  are  used  hypodermatically  in  doses 
of  from  Yg-Q-  to  ^  of  a  grain.  Almost  immediately  after  injection  the 
muscles  become  inco5rdinated  and  weak,  and  in  ten  or  fifteen  minutes 
the  patient  sinks  into  a  light  slumber  which  lasts  from  six  to  eight 
hours.  The  peripheral  arteries  are  contracted,  giving  the  patient  a 
striking  pallor ;  the  breathing  is  slowed,  the  pulse  retarded  or  made  in- 
termittent, the  throat  rendered  very  dry,  and  the  pupils  enlarged  and 
accommodation  paralyzed.  These  drugs  are  contraindicated  in  heart 
disease,  and  in  no  case  should  they  be  continued  any  length  of  time. 


768  31  EXT  A  L   DISEASES. 

Precious  as  they  are  on  the  right  occasion,  their  employment  should  be 
subject  always  to  the  careful  and  judicious  supervision  of  the  physician. 

Another  feature  of  their  physiological  action  to  be  borne  in  mind  is 
their  power  to  induce  dreadful  hallucinations  in  a  well  person — a  fact 
which  emphasizes  the  need  of  care  in  administering  them  to  an  indi- 
vidual wliose  mind  is  trembling  in  the  balance.  Long-continued  use 
of  these  alkaloids  interferes  with  uutriti(jn. 

From  what  has  been  said  of  the  action  of  these  drugs,  it  will  be  seen 
that  their  eifectiveness  is  most  manifest  in  conditions  of  motor  excite- 
ment, in  mania,  agitated  melancholia  (combined  with  morphia),  in 
agitated  dementia,  and  in  the  motor  excitement  of  epilepsy  or  paresis. 
I  have  often  been  able  to  feed  excited  patients  who  refused  food,  imme- 
diately after  the  injection  of  the  alkaloid,  during  the  few  minutes  that 
elapse  before  the  advent  of  sleep. 

The  bromids,  aside  from  their  particular  value  in  epileptic  psy- 
choses, are  often  useful  in  other  forms  of  mental  disease,  owing  to  their 
efPect  in  diminishing  cerebral  activity  and  reflex  irritability.  In  epilep- 
tic insanities  the  combination  of  the  bromids  and  opium  is  especially 
effective.  They  are  of  use  in  any  mental  excitement  which  is  con- 
joined with  some  reflex  irritability  (illusions  and  organic  sensations, 
uterine  and  genital  disorders).  As  an  anti-aphrodisiac  they  are  employed 
in  insanity  with  erotic  manifestations.  In  large  doses,  sixty  to  ninety" 
grains  and  over,  they  act  well  as  a  safe  and  innocuous  hypnotic. 

Chloral  hydrate  is  not  so  much  used  as  formerly,  though  its  hyp- 
notic effect  resemljles  very  closely  natural  sleep.  It  is  applicable  to 
acute  hallucinatory  conditions,  insanities  associated  with  chorea,  and  in 
the  epileptic  psychoses.  In  status  epilepticus,  per  rectmn  it  is  one  of 
the  most  valuable  remedial  agents.  In  some  conditions,  combinations 
of  chloral  with  morphin  are  of  much  utilit}*.  Chloral  is  a  heart  poison, 
and  its  use  is  contraindicated  in  cardiac  and  vascular  disease.  Chloral- 
amid  is  of  little  value. 

Paraldehyd  is  a  simple  hypnotic  whose  utility  is  not  sufficiently 
appreciated.  Xaturally,  its  bad  taste  and  the  rather  disagreeable  odor 
left  upon  the  breath  have  limited  its  sphere  of  useftilness  ;  but  it  has 
no  bad  influence  upon  the  heart  or  nutrition.  It  can  be  given  in  heart 
disease,  and  patients  seem  to  thrive  and  grow  fat  upon  it.  The  dose  is 
from  one-half  to  two  drams,  but  increasing  dose-  are  necessary,  and  I 
have  had  patients  who  have  taken  four  or  more  drams  at  a  dose.  It  is 
especially  useful  in  conditions  of  inanition  and  in  insanities  foiuided 
upon  hysteria  or  neurasthenia.  The  taste  and  odor  of  the  drug  can  be 
concealed  in  orange-water  or  weak  brandy.  Amylene  hydrate  is  of  less 
value  ;  it  stands  l^etween  chloral  and  paraldehvd. 

Trional  and  sulphonal,  as  simple  sleep-producing  agents,  are  preemi- 
nent where  nothing  but  sleep  is  the  object  to  be  attained.  Trional  acts 
quickly,  sulphonal  slowly  ;  hence  a  combination  of  the  two  in  equal  doses 
is  particularly  fortunate  in  its  results,  inducing,  as  it  does,  rapid  and 
prolonged  slumber.  Five  to  ten  grains  each,  or  more  if  indicated,  may 
be  given  at  bedtime  with  a  glass  of  hot  milk.  The  tastelessness  of  these 
drugs  affords  the  possibility  of  administering  them  without  the  knowledge 


GENERAL    TREAT^fENT  OF  INSANITY.  769 

of  the  patient,  mixed  with  salt  or  sugar,  or  spread  with  butter  upon  bread. 
Sulphonal  used  for  a  long  period  produces  muscular  weakness  and  in- 
coordination. Both  of  these  agents  may,  after  a  time,  give  rise  to  some 
disorder  of  the  alimentary  canal.  They  are  said  to  occasionally  increase 
the  intensity  of  auditory  hallucinations. 

Moral  Treatment. — Psychotherapy  is  among  the  most  important 
means  of  treatment  of  insanity.  The  general  practitioner  is  especially 
concerned  with  it  in  the  early  stages  of  mental  disorder ;  later,  if  the 
patient  is  turned  over  to  the  care  of  the  asylum,  it  is  still  of  the  utmost 
importance,  and  the  physicians  in  institutions  know  well  the  necessity 
and  utility  of  moral  agencies  in  effecting  a  cure  or  in  at  least  amelio- 
rating the  condition  of  their  charges.  Physicians  who  have  much  to  do 
with  ordinary  functional  nervous  disorders — hysteria,  neurasthenia,  mild 
depression,  and  hypocliondriasis — are  familiar  with  the  wonderful  influ- 
ence they  are  able  to  exert  over  the  mental  attitude  of  patients  thus 
afflicted,  by  kindness,  patience,  firmness,  interest,  and  sympathy.  Every- 
thing they  say  or  do,  if  rightly  said  or  done,  conveys  a  suggestion, 
inspires  hopefulness,  increases  the  efficacy  of  their  prescriptions,  points 
out  the  way  to  health  and  a  new  lease  of  life.  The  insane  also  are  in 
the  same  way  dominated  by  the  personality  of  the  physician  and  of 
those  chosen  to  carry  out  his  instructions.  Some  physicians  are  fortu- 
nate enough  to  possess  peculiar  gifts  in  this  way,  and  their  influence  is 
potent  for  incalculable  good.  Aside  from  this  personal  influence,  the 
physician  is  called  upon  to  direct  and  regulate  the  entire  disposition  of 
the  time  of  the  patient  and  to  make  for  him  the  environment  suitable  to 
his  malady.  He  prescril^es  isolation  from  friends,  the  care  of  strangers, 
the  rest-cure,  the  periods  and  kinds  of  exercise,  the  mental  and  manual 
occupations,  the  amusements,  all  of  which  go  to  make  up  psychotherapy. 
Some  of  the  principles  of  this  moral  treatment  we  will  now  briefly  touch 
upon. 

The  value  of  isolation  in  melancholia  and  of  the  rest-cure  for  both 
acute  mania  and  melancholia  has  already  l^een  mentioned.  There  are 
cases  of  melancholia,  however,  in  which  a  modified  rest-cure  is  better 
than  the  complete  rest-cure.  In  such  cases,  after  recumbence  in  bed 
from  six  in  the  evening  until  noon  the  next  day,  much  of  the  afternoon 
may  be  spent  in  simple  exercise,  such  as  walking  slowly  about  out-of- 
doors.  It  is  best  not  to  seek,  by  amusements,  visits  of  friends,  and  other 
cheerful  devices,  to  raise  the  melancholiac  from  his  depression,  for  usually 
these  attempts  rather  add  to  his  misery  by  force  of  contrast.  A  neutral 
atmosphere,  so  far  as  the  emotions  are  concerned,  is  best,  though  an 
occasional  word  of  confident  reassurance  is  useful. 

In  acute  stages  of  insanity  it  is  best  not  to  discuss  the  hallucinations 
and  delusions  of  the  patient,  although  neither  physician  nor  nurse 
should  ever  fall  in  with  or  act  upon  his  erroneous  ideas.  Whenever 
good  judgment  suggests,  a  brief  but  positive  denial  of  the  truth  of  the 
imaginings  of  the  patient  should  be  made.  Later  on  such  correction 
may  with  advantage  be  made  more  frequently  and  constantly. 

When  the  patient  is  not  taking  a  rest-cure,  occupation  of  some  kind 
is  essential  to  his  progress  toward  recovery.  Most  useful  are  all  forms 
49 


770  MENTAL   DISEASES. 

of  muscular  or  manual  employment,  for  labor  of  this  kind  keeps  the 
attention  more  or  less  fixed  upon  what  is  being  done,  the  flow  of  ideas 
is  checked  and  limited  to  a  considerable  degree,  and  the  mind  is  pre- 
vented from  concentrating  itself  upon  illusions,  hallucinations,  and 
delusions.  Moreover,  muscular  exercise  is  an  outlet  for  superfluous 
energy ;  motor  excitement  is  reduced  by  it ;  tissue  metabolism  is  accel- 
erated ;  and  when  the  work  is  over,  the  organism  gains  all  the  more 
readily  a  certain  composure  of  mind  and  repose  of  body.  Out-of-door 
occupation  is  best — garden  and  field  work  for  men,  garden  work  for 
women  ;  walking,  bicycling,  etc.,  for  either  sex.  Among  indoor  em- 
ployments we  have  ordinary  housework,  drawing,  knitting,  sewing, 
embroidery,  carpentry,  wood-carving,  etc.,  all  of  which  employ  the 
muscles  methodically.  In  certain  cases  mental  occupation  is  useful, 
though  it  should  be  of  the  simplest  kind.  For  instance,  during  my 
practice  at  the  Hudson  River  State  Hospital  for  the  Insane,  we  found 
much  value  in  the  establishment  of  a  regular  country  school,  attended 
by  patients  of  all  ages.  AVe  had  "■  spelling  bees,"  copying  lessons, 
reading  aloud,  blackboard  exercises,  geography,  simple  arithmetic,  sing- 
ing, and  so  on. 

A  very  important  point  in  the  management  of  the  insane  is  never  to 
practise  deception  upon  them  in  any  way.  Be  absolutely  truthful  in 
every  statement  to  them.  Never  remove  a  patient  to  an  asylum  under 
the  impression  that  it  is  a  hotel  or  sanatorium.  It  is  better  to  state 
exactly  what  is  going  to  be  done,  and  then  use  force  in  the  removal,  if 
necessary. 

Hypnotism  has  been  frequently  practised  upon  the  insane,  in  the 
effort  to  modify  hallucinations  or  delusions,  rarely  with  any  definite 
success,  occasionally  with  ill  results,  and  generally  with  no  effect  what- 
ever. 

There  are  a  few  conditions  among  the  insane  which  require  particular 
treatment  or  management.     Among  them  are  : 

Suicidal  Tendencies. — Suicidal  patients  are  among  those  who 
require  constant  watching  and  the  removal  of  every  means  of  self- 
injury.  This  is  often  difficult  in  treating  such  patients  in  their  own 
homes.  How  difficult,  it  may  be  conjectured  from  the  fact  that,  even  in 
asylums,  with  all  their  safeguards,  suicide  is  by  no  means  infrequent. 
Thus,  forty-eight  patients  in  the  asylums  of  the  State  of  New  York 
committed  suicide  between  October  1,  1888,  and  September  30,  1896. 

Suicidal  patients  are  to  be  watched  night  and  day,  and  kept  in  bed, 
and  even  put  in  restraint,  if  desperate.  I  have  known  a  patient  to 
strangle  herself  with  a  cord  while  lying  in  bed  under  the  eye  of  a 
nurse.  Another,  broke  a  small  piece  from  a  china  plate  and  tried  to  cut 
her  wrists  under  the  bedclothes.  While  suicide  is  most  common 
among  melancholiacs,  patients  with  general  paresis,  paranoia,  epileptic 
psychoses,  and  toxic  delirium  sometimes  attempt  it.  The  physician 
attending  such  patients  should  see  to  the  guarding  of  windows  and  the 
removal  of  keys,  hooks,  scissors,  weapons,  drugs,  strings,  long  pins, 
matches — in  fact,  of  all  instruments  and  means  which  he  may  suspect 
to  be  utilizable  for  a  suicidal  purpose. 


GENERAL    TEEAT3IENT  OF  INSANITY.  771 

Refusal  of  Food. — The  acutely  maniacal  often  can  not  be  made  to 
take  sufficient  nourishment,  because  they  do  not  stop  long  enough  in 
their  ideomotor  excitement  to  permit  of  eating.  The  watchful  and  per- 
severing nurse  can  generally,  by  persistent  effort,  induce  the  patient  to 
swallow  a  considerable  quantity  of  liquid  food  (preferaljly  in  a  metal  or 
heavy  china  cup,  because  the  patient  frequently  knocks  the  vessel  from 
the  hand  of  the  nurse).  Such  patients  can  often  be  fed,  as  already 
stated,  immediately  after  a  hypodermatic  injection  of  hyoscin  or  duboi- 
sin  before  the  supervention  of  sleep. 

Other  patients  refuse  to  eat  because  of  delusions  of  j)overty  or 
poisoning,  suicidal  proclivity,  or  simply  from  absolute  distaste. 

Where  ordinary  means  fail,  the  nasal  tube  should  be  resorted  to, — 
one  of  large  caliber  with  rubber  funnel  attached, — and  through  this, 
once  or  twice  daily,  a  mixture  of  a  pint  of  milk,  two  or  three  raw  eggs, 
a  little  meat-juice,  and,  if  needed,  brandy,  may  be  introduced. 

Before  resort  to  this  means  nutritive  enemata  may  be  employed 
(three  raw  eggs,  a  half-pint  of  milk,  a  half-pint  of  water,  and  a  little 
meat-juice). 

I  have  l)een  in  the  habit  of  delaying  the  use  of  the  nasal  or  stomach- 
tube  to  the  last  moment  of  safety,  even  for  several  days,  rather  than 
subject  the  patient  to  the  excitement  of  its  employment.  It  is  only  in 
rare  instances  that  feeding  is  not  effected  in  some  other  way  before  the 
use  of  the  tube  becomes  imperative. 

Violence  and  Destructiveness. — Hypodermatic  medication  and  hot 
wet-packs  are  indicated  in  periods  of  excitement  with  tendency  to  vio- 
lence and  destructiveness.  It  has  already  been  intimated  that  active 
physical  labor  or  exercise  is  a  safet}^-valve  for  patients  with  proclivities 
of  this  kind.  Isolation  in  an  empty  room  with  protected  windows  is 
sometimes  resorted  to  in  institutions,  and  abroad  the  padded  room  is  a 
favorite  place  for  patients  whose  violent  jactitations  may  lead  to  serious 
injuries  to  himself.  The  padded  room  consists  simply  of  a  room  lined 
as  to  walls  and  floor  with  cushions.  Mechanical  restraint  is  used  in  the 
last  extremity,  when  chemical  restraint  and  other  means  have  failed. 
The  camisole  and  safety-sheet  are  employed  only  in  cases  with  desperate 
suicidal  tendencies,  proclivity  to  excessive  masturbation,  great  violence 
and  destructiveness,  and  where  needed  to  keep  in  place  surgical  dress- 
ings, splints,  etc.  In  asylums  mechanical  restraint  has  been  nowadays 
almost  entirely  abandoned. 

Masturbation. — Masturbation  is  more  often  the  consecpience  and 
concomitant  of  insanity  than  its  cause.  It  may  be  ameliorated  occa- 
sionally by  drugs  like  bromids,  camphor,  and  lupulin.  Cold  baths  and 
hard  physical  labor  are  more  successful  in  combating  this  hal)it.  In 
excessive  masturbation,  constant  watching  day  and  night  or  the  use  of 
mechanical  restraint  is  necessary.  The  use  of  blistering  fluids  on  the 
genital  organs  is  only  of  temporary  service.  There  are  instances  in 
which  the  habit  is  so  fixed  and  so  uncontrollable — for  example,  among 
some  imbeciles — that  surgical  interference  would  ])e  quite  justifiable 
(castration,  clitoridectomy,  ovariotomy,  section  of  the  pudic  nerves, 
ligation  of  the  vas  deferens). 


772  MENTAL   DISEASES. 


CHAPTER  VI. 
MANIA. 

Definition. — Mania  is  a  form  of  insanity  characterized  by  emotional 
exaltation,  acceleration  of  the  flow  of  ideas,  and  motor  agitation.  It  is 
probable  that  the  elated  mood  and  the  hyperex citation  of  intellectual 
processes  are  both  primary  and  simultaneous  in  their  development. 
The  motor  excitement  results  from  the  conversion  of  the  swiftly  flowing 
ideas  into  acts. 

Etiology. — There  is  no  special  etiology  for  mania — what  has  been 
said  in  the  chapter  on  General  Etiology  has  application  to  this  form.  It 
may  be  said,  however,  that  mania  is  ordinarily  a  disorder  arising  between 
the  twelfth  and  twenty-fifth  years  ;  that  it  is  more  common  in  females 
than  in  males ;  that  individuals  of  sanguine  temperament  are  most 
liable  ;  and  that  it  is,  upon  the  whole,  rather  an  infrequent  type  of  in- 
sanity. Hereditary  taint  is  found  in  seventy-five  per  cent,  and  degen- 
erative stigmata  in  twenty  per  cent,  of  cases.  The  percentage  is  larger 
for  the  periodical  form. 

Mental  Symptoms. — An  outbreak  of  mania  is  preceded  by  a 
period  of  depression  lasting  from  a  few  days  to  a  few  weeks,  sometimes 
as  long  as  two  months.  This  prodromal  stage  is  characterized  by  a 
general  feeling  of  malaise,  vague  uneasiness,  and  hypochondriacal  com- 
plaints, accompanied  often  by  headaches,  cephalic  paresthesias,  constipa- 
tion, loss  of  appetite,  sleeplessness,  and  some  loss  of  flesh. 

When  the  true  mental  disorder  begins  to  manifest  itself,  the  sorrowful 
mood  begins  to  give  way  to  an  exalted  condition,  which  the  patient 
looks  upon  as  a  state  of  renewed  health  and  well-being.  He  takes  a 
renewed  interest  in  everything,  and  becomes  unusually  cheerful  and 
talkative.  The  degree  of  increasing  exaltation  varies  much  in  different 
cases.  In  mild  cases  the  patient  begins  to  surprise  his  intimates  by  his 
loquacity,  facetious  remarks,  jocularity,  and  by  his  rather  immoderate 
actions  and  undertakings.  He  enters  upon  many  new  schemes  ;  makes 
innumerable  calls  upon  friends  and  acquaintances ;  writes  numberless 
letters  ;  purchases  unnecessary  articles  ;  and  is  inclined  to  excessive  in- 
dulgence in  tobacco,  wine,  and  venery.  There  is  considerable  mobility 
or  lability  of  the  emotions,  so  that  the  elation  may  readily  pass  into 
conditions  of  anger  or  tears  over  trifles.  In  more  severe  types  all  of 
these  symptoms  are  aggravated.  A  veritable  chaos  of  ideas  throngs 
through  his  mind,  and  the  efi^ects  upon  movement  of  this  crowding  series 
of  ideas  amount  to  a  constant  motor  agitation.  The  patient  laughs, 
declaims,  sings,  shouts,  makes  grimaces,  dances,  runs  about,  and  becomes 
destructive  and  filthy,  all  inhibitory  idea-associations  ceasing  to  have 
any  influence  over  the  rioting  torrent  of  thought.  In  still  severer 
grades  we  have  the  picture  of  an  acute  delirium,  boisterous  incoherence, 
a  motor  agitation  attaining  to  violent  jactitation,  and  an  actual  and  con- 
siderable increase  of  temperature. 


MANIA. 


773 


The  patient  with  mania  is  fundamentally  optimistic  and  es::otistic. 
Everything'  about  him  is  njse-colored.  He  feels  rejuvenated  ;  rejoices  in 
his  health,  strength,  and  vitality  ;  is  delighted  with  the  vivacity  of  his 
ideas  and  the  iiutrammeled  virility  of  his  intellectual  processes.  His 
general  and  special  sensibilities  are  ordinarily  unattected ;  in  only  about 
one-fifth  of  the  cases  are  illusions  and  hallucinations  present,  and  these 
are  almost  always  limited  to  vision.  Occasionally  there  are  illusions 
and  hallucinations  of  taste  and  touch.  Illusions  of  the  special  senses 
are  more  frequent  than  hallucinations.  The  manias  of  extreme  youth 
or  age  and  alcoholic  mania  are  especially  prone  to  manifest  hallucina- 
tions. Mania  marked  by  the  presence  of  numerous  illusions  and  hallu- 
cinations is  often  designated  as  hallucinatory  mania. 

The  accelerated  flow  of  ideas  in  mania  is  naturally  most  conspicuous 
in  the  speech  of  the  patient,  which  varies  from  garrulity  to  logorrhea. 
In  the  milder  degrees  of  loquacitv^  we 
are  still  able  to  follow  the  sequence  of 
associations.  The  sentences  are  often 
bound  together  by  the  ordinary  relation- 
ship and  connections  of  ideas,  but  among 
which  many  latent  ideas  spring  into  con- 
sciousness and  expression  ;  and,  again, 
the  soimds  of  words  spoken  suggest 
others  of  similar  sound,  giving  rise  to 
rimes  and  assonances.  Thus,  the  sight 
of  the  physician  may  suggest  drugs,  a 
certain  apothecary,  in  a  special  street, 
in  some  familiar  town ;  and  the  town 
may  in  turn  give  rise  to  another  series. 
On  the  other  hand,  the  physician's  "How 
do  you  do?"  may  invoke  a  string  of 
assonances  (verbigeration)  commingled 
with  sentences  expressing  their  associ- 
ated ideas — shoe,  two,  new,  grew,  blue, 
crew,  etc.  But  in  the  more  striking 
grades  the  logorrhea  is  so  pronounced 

that  it  is  impossible  to  find  clues  to  any  association,  whether  of  sound 
or  idea.  It  becomes  a  chaos  of  words,  consequent  upon  an  actual  dis- 
sociation of  the  ideas  in  the  rushing  stream  of  thought — a  secondary 
incoherence.  The  entire  loss  of  inhibitory  control  of  ideas  is  especially 
shown  in  the  absolute  lack  of  modesty,  in  the  tendency  to  the  employ- 
ment of  vulgar  and  obscene  words  and  expressions.  This  profanity 
and  obscenity  become  all  the  more  astonishing  by  contrast,  when  it  is 
observed,  as  it  often  is,  even  in  the  most  refined  and  cultured  of  women. 

The  attention  of  the  patient  with  mania  is  extraordinarily  increased, 
60  that  the  most  insignificant  trifle  in  his  environment  does  not  escape 
him.  But  this  very  increase  of  the  power  of  attention,  combined  as  it 
is  with  an  unpausing  stream  of  ideas,  entails  an  absolute  lack  of  con- 
centration. His  attention  can  not  be  held  a  moment.  The  patient's 
memory,  too,  seems  preternaturally  intense,  and  it  is  remarkable  how, 


-3Iauia  i^puerpei';; 


774  MENTAL  DISEASES. 

after  recovery,  he  may  remember  all  the  details  of  his  delirious  activity 
with  great  distinctness.  Indeed,  the  patient,  in  the  midst  of  the  chaotic 
turmoil  of  his  mind,  often  recognizes,  as  if  he  stood  apart  from  and 
judged  himself,  the  very  madness  of  his  fancies  and  acts.  The  judg- 
ment-associations are,  in  fact,  normal, 

Tlie  elated  mood  and  rapid  flow  of  ideas  give  rise  to  delusions  of 
expansive  character,  mostly  in  regard  to  strength,  beauty,  and  intel- 
lectual powers,  but  often  also  in  relation  to  wealth,  social  position,  etc. 
In  severe  cases  there  are  the  most  marked  delusions  of  grandeur,  the 
patient  affirming  himself  or  herself  to  be  a  prince,  president,  king, 
queen,  Christ,  the  bride  of  Christ,  the  mother  of  God,  etc.  A  peculiarity 
of  these  affirmations  is  their  transitory  character,  their  impermanence. 
A  patient  will,  in  the  same  breath,  call  himself  a  millionaire,  broker, 
and  king,  and  in  the  next  a  minister  of  the  gospel  and  railroad  magnate. 
If  sharply  told  by  the  physician  to  stop  such  nonsense,  he  will  often 
say  it  was  only  a  joke,  or  he  had  said  such  things  for  fun.  This  shows 
very  well  the  latent  consciousness  of  the  patient  of  the  true  state  of 
affairs. 

The  sexual  instinct  is  morbidly  exalted,  giving  rise  in  both  sexes  to 
immodesty  and  obscenity  of  speech  and  manner,  and  often  to  sexual 
excesses  and  masturbation. 

The  actions  of  patients  with  mania  correspond  in  character  to  the 
degree  of  acceleration  in  the  stream  of  ideas.  When  this  is  very  great, 
turbulence,  violence,  and  destructiveness  are  common,  not  with  any 
homicidal  or  suicidal  intent,  because  they  are  incapable  of  acts  requiring 
any  particular  concentration  of  mind  or  reflection,  but  simply  as  the 
result  of  uncontrollable  automatic  impulsions. 

Sleeplessness  is  characteristic  of  this  condition.  General  sensibility 
appears  to  be  benumbed,  probably  because  of  the  want  of  concentration 
of  thought.  Patients  seem  insensible  to  changes  of  temperature  and  to 
severe  pain.  Such  a  state  often  masks  the  most  serious  disorders,  like 
pneumonia  or  the  pains  of  labor.  I  once  made  an  autopsy  upon 
a  woman  suffering  from  acute  mania  who  died  suddenly.  She  had  been 
for  days  in  the  wildest  uproar  of  mind  and  body.  The  cause  of  death 
was  an  acute  peritonitis  from  rupture  of  a  perforating  duodenal  ulcer. 
The  peritonitis  had  evidently  existed  for  several  days,  yet  this  painful 
affection  had  clearly  had  no  effect  upon  the  course  of  the  mental  and 
motor  symptoms. 

Some  cases  of  mild  maniacal  character  exhibit  a  peculiar  tendency  to 
logically  explain  and  excuse  their  insane  acts,  and  this  type  is  often 
designated  as  reasoning  mania. 

As  already  stated,  mania  begins  with  a  prodromal  stage  of  depression. 
After  the  exalted  stage  has  culminated  and  at  the  beginning  of  conva- 
lescence, a  reactive  stage  of  depression  is  presented,  characterized  by 
irritability,  sensitiveness,  and  lacrymosity.  This  stage  of  depression 
may  be  so  intense  as  to  be  an  actual  melancholia  of  simple  nature  or 
accompanied  with  stupor.  In  instances  of  this  kind  the  possibility  of 
the  patient's  having  a  circular  form  of  insanity,  instead  of  a  simple 
mania,  is  to  be  considered. 


MANIA.  775 

Physical  Symptoms. — Except  in  the  severest  type  of  mania  (acute 
delirium)  the  bodily  temperature  runs  a  normal  course,  sometimes  even 
showing  a  subnormal  character.  In  acute  delirium  the  temperature 
may  reach  104°  or  105°  or  more.  The  pulse  is  small  and  normal, 
or  but  slightly  increased  in  frequency  in  mania.  There  are  no  paraly- 
ses, no  true  anesthesias.  The  absence  of  fatigue  is  often  surprising. 
The  deep  reflexes  are  exaggerated,  as  a  rule.  The  salivary  secretion 
is  frequently  increased.  Perspiration  is  diminished  and  sometimes 
transformed  in  character,  so  as  to  give  a  peculiar  and  often  extremely 
disagreeable  odor  (kakidrosis).  Gastric  disorders  are  nearly  always 
manifested,  and  the  tongue  is  heavily  furred,  frequently  dry.  In 
severe  cases  albuminuria,  propeptonuria,  and  hyalin  cylinders  are 
frequently  found.  The  general  bodily  weight  diminishes  during  the 
progress  of  the  disease,  but  rapidly  increases  with  convalescence.  There 
is  a  corresponding  condition  of  the  appetite,  an  anorexia  during  the 
early  stage  and  until  the  culmination ;  then  an  increase  of  appetite 
amounting  often  to  bulimia.  The  face  is  sometimes  slightly  suffused, 
but,  as  a  rule,  marked  by  a  yellowish  pallor.  As  the  patient  emaciates 
this  becomes  more  noteworthy,  and  at  the  same  time  the  features 
become  pinched  and  sharp  and  the  eyeballs  sunken.  This  outline  and 
color  of  the  face,  with  a  tendency  to  dryness  of  the  lips  and  a  heavily 
furred  and  dry  tongue,  are  indications  of  the  progress  of  exhaustion. 

Varieties. — According  to  the  intensity  of  the  manifestations,  upon 
the  basis  of  the  course  of  the  disease,  from  the  nature  of  certain  con- 
comitant symptoms,  and,  fourthly,  in  relation  to  some  of  the  etiological 
factors,  mania  is  frequently  divided  into  several  varieties  bearing  some 
special  qualification.  I  have  already  alluded  to  mild  and  severe  degrees 
of  mania, — mania  mitis,  mania  grains,  and  acute  delirious  mania, — which 
shade  off  gradually  with  many  intermediate  stages  from  one  into  the 
other.  I  have  also  mentioned  reasoning  and  haUucinatori/  mania,  which 
owe  their  names  to  peculiarities  in  the  symptoms.  It  is  customary  to 
speak  also  of  acute,  subacute,  and  chronic  mania,  the  first  two  designa- 
tions referring  especially  to  the  rapidity  or  slowness  of  onset,  the  last 
Cjualification  to  the  duration  of  the  insanity  in  its  maniacal  form  for  a 
year  or  many  years.  The  w^ord  chronic  does  not  mean  incurable,  for 
cases  of  chronic  mania  of  long  standing  not  infrequently  recover.  The 
term  transitory  mania  was  formerly  employed  to  describe  a  delirious 
condition  of  very  brief  duration,  a  few  hours  or  a  day  or  two,  but  these 
cases  do  not  really  present  the  characteristic  symptoms  of  a  true  mania. 
Periodic  mania  is  a  form  in  which  attacks  of  mania  follow  one  another 
with  perfectly  iwrmal  but  generally  irregular  intervals  of  days,  months, 
weeks,  or  years.  The  attacks  themselves  last  from  a  few  days  to  a  few 
months.  Usually  the  prodromal  depressive  stage  is  absent,  the  culmi- 
nation rapid,  and  convalescence  seldom  marked  by  the  interesting 
depressive  affects  of  ordinary  mania.  The  periodic  attacks  are  very  apt 
to  be  distinguished  by  the  presence  of  special  symptoms,  such  as  a 
reasoning  tendency,  tendencies  to  impulsive  acts,  arson,  stealing,  assaults, 
sexual  and  alcoholic  excesses,  and  to  severe  headaches.  The  longer 
periodic  mania  endures,  the  less  distinct  become  the  normal  features  of 


776 


MENTAL  DISEASES. 


the  intervals.  Recurrent  mania  and  intermittent  mania  are  only  other 
names  for  periodic  mania.  Various  etiological  factors  give  rise  to  such 
designations  as  epileptic,  alcoholic,  morphin,  puerperal,  senile  mania, 
etc.,  in  some  of  which  the  mania  takes  a  special  color  from  its  cause. 
Thus,  the  toxic  manias  are  generally  acute  hallucinatory  conditions. 

Pathology. — The  most  careful  investigations  of  the  central  nervous 
system  have  thus  far  discovered  no  pathologico-anatomical  basis  for 
mania.  The  theory  still  prevails  that  there  is  a  condition  of  congestion 
of  the  higher  brain-centers  underlying  the  manifestations  of  mania,  but 
this  theory  lacks  the  support  of  observed  facts.  We  are,  therefore, 
constrained  to  look  upon  the  disorder  as  functional  in  its  nature,  as  due 
to  a  morbid  change  in  the  nutrition  of  the  cells,  in  the  way  of  deficient 
or  perverted  metabolism. 

Course  of  the  Disease. — Mania  terminates  in  recovery,  death, 
secondary  dementia,  secondary  paranoia,  or  chronic  mania. 

Recovery  takes  place  in  some 
seventy  per  cent,  of  cases.  Some- 
times it  is  exceedingly  rapid,  but 
usually  the  progress  is  gradual  and 
rhythmical  to  the  normal  state.  This 
rhythm  is  a  sort  of  oscillation  be- 
tween good  and  bad  days,  but  with 
constant  improvement.  Occasion- 
ally the  patient  improves  steadily 
and  uninterruptedly  until  recovered. 
Recovery  is  sometimes  not  perfect, 
so  that  we  speak  of  it  as  recovery 
with  defect. 

Death  takes  place  in  but  five  per 
cent  of  cases.  The  cause  of  death 
is  sometimes  exhaustion,  as  in  acute 
delirium  ;  more  often  an  intercurrent 
affection,  such  as  pneumonia,  neph- 
ritis, and  the  like.  Heart  disease 
and  alcoholism  add  greatly  to  the 
danger  of  lethal  termination. 

Dementia  is  the  result  of  the 
disorder  in  about  one-tenth  of  the 
cases.  The  degree  of  dementia 
varies  from  a  slight  diminution  in  some  of  the  higher  qualities  and 
powers  of  the  mind  to  pronounced  mental  enfeeblement  with  vestiges 
of  the  antecedent  mania  and  complete  confusion  and  incoherence.  The 
vestiges  of  the  antecedent  mania  are  commonly  in  the  form  of  motor 
agitation,  and  occasionally  hallucinations  and  rudimentary  delusions  of 
exalted  character. 

A  paranoia  secondary  to  mania  is  met  with  in  rare  instances,  perhaps 
once  among  a  hundred  cases.  In  such  termination  we  observe  a  tendency 
to  the  systematization  of  some  of  the  original  maniacal  delusions. 

Chronic  mania  is  quite  as  rare  a  condition  as  secondary  paranoia.    By 


Fig.  304.— Chronic  mania. 


3IANIA.  777 

this  term  is  meant  a  eontinuance  of  the  typical  maniacal  symptoms  for 
a  long  period  of  time — a  year  or  many  years. 

It  must  be  remembered,  too,  that  an  attack  of  acute  or  subacute 
mania  may  be  merely  the  beginning  of  a  periodic  mania  or  of  a  circular 
insanity. 

Diagnosis. — One  must  be  careful  not  to  confound  delirium  from 
fever  with  an  attack  of  acute  mania.  Except  in  acute  delirious  mania,  the 
absence  of  fever  in  the  mental  disorder  should  be  distinctive.  The  three 
cardinal  symptoms  of  mania  should  be  kept  constantly  in  mind — viz., 
the  exalted  mood,  the  accelerated  flow  of  ideas,  and  the  motor  excitement. 
We  must  determine  whether  these  are  primary  or  secondary  to  halluci- 
nations and  delusions,  and  whether  the  syndrome  is  complicated  by 
other  conditions,  such  as  general  paralysis  and  alcoholism.  A  very 
mild  degree  of  mania  may  pass  unrecognized,  nnless  it  is  possible  to 
diagnose  it  from  a  pronounced  change  in  the  character  of  the  individual 
and  from  the  accompanying  insomnia.  The  physical  symptoms  and 
the  defect  of  intellect  should  suffice  to  distinguish  the  exalted  stage  of 
general  paresis  from  an  acute  mania.  The  delusions,  too,  of  paresis 
have  a  peculiar  monstrosity  of  character  that  differentiates  them  from 
the  exalted  ideas  of  the  maniac.  Sometimes,  however,  there  will  be 
difficulty  in  making  a  speedy  diagnosis  between  these  two  analogous 
exalted  conditions. 

In  acute  hallucinatory  paranoia  we  may  encounter  the  three  emo- 
tional symptoms  of  acute  mania,  but  on  examination  these  will  be 
found  not  to  be  primary  in  their  origin,  but  secondary  to  the  hallucina- 
tions. In  the  epileptic  type  of  acute  hallucinatory  paranoia  defects  of 
memory  are  distinctive. 

Subacute  types  of  mania  may  resemble  congenital  states  of  mental 
weakness,  in  so  far  as  excesses,  moral  delinquencies,  etc.,  are  concerned. 
Here,  too,  intellectual  defect  and  the  early  history  will  serve  to  difFer- 
entiate  the  condition  of  congenital  feeble-raindedness. 

We  can  never  determine  from  a  single  attack  whether  we  have  before 
us  a  form  of  periodic  mania  or  circular  insanity.  It  is  only  the  suc- 
cession of  outbreaks  and  the  cyclical  character  that  can  serve  us  here. 

Prognosis. — Some  of  the  prognostic  data  are  apparent  from  what 
has  gone  before.  In  the  main  the  outlook  is  favorable,  since  so  large 
a  percentage  of  the  cases  recover.  After  six  months  have  passed  the 
prognosis  becomes  only  half  as  good,  and  after  two  or  three  years  is 
quite  unfavorable.  There  are  exceptional  instances  of  recovery  after 
many  years.  The  younger  the  patient,  the  better  the  chance  for  cure.  A 
second  or  third  attack  may  be  recovered  from  completely,  if  they  be 
merely  recedival  attacks  ;  but  if  they  indicate  a  periodic  insanity,  the 
outlook  is  unpromising. 

Treatment. — AVhat  has  already  been  said  in  the  chapter  on  General 
Treatment  is  applicable  here.  The  requisite  isolation  and  supervision 
of  a  patient  with  acute  mania  can  seldom  be  satisfactorily  accomplished 
outside  of  an  asylum,  unless  his  means  are  sufficient  to  secure  the  needed 
nurses  and  suitable  surroundings. 

Eest  in  bed  aids  in  the  prevention  of  exhaustion,  and  renders  super- 


778  3IENTAL   DISEASES. 

vision,  care,  and  feeding  more  easy.  To  induce  sleep  and  allay  motor 
excitement,  hydrotherapy  and  the  hypodermatic  use  of  hyoscin,  hyoscy- 
amin,  or  duboisin  are  extremely  valuable.  In  mild  cases,  equal  parts 
of  trional  and  sulphonal  are  preferable  to  the  drugs  just  mentioned. 
Paraldehyd  is  also  an  excellent  hypnotic  for  mild  cases. 

Overfeeding  is  also  an  extremely  important  indication.  Liquid  and 
easily  digested  foods  are  to  be  recommended.  The  bowels  should 
always  be  regulated.  Brandy  is  added  to  the  liquid  food  when  ex- 
haustion is  imminent,  but  otherwise  stimulants  are  contraindicated. 
Should  there  be  danger  of  collapse,  the  repeated  hyjDodermatic  injections 
of  ordinary  salt  and  water  (ten  to  fourteen  ounces)  over  the  abdomen 
or  in  the  thigh  are  valuable.  In  the  depressed  period  of  convalescence 
small  doses  of  opium  are  often  useful. 


CHAPTER  VII. 
MELANCHOLIA. 

Definition. — Melancholia  is  a  mental  disorder  characterized  by  a 
primary  depressed  mood  associated  with  retarded  flow  of  thought,  and 
either  motor  inliibition  or,  in  some  instances,  with  an  agitation  expres- 
sive of  anxiety  and  apprehension. 

Etiology. — Heredity  is  encountered  in  fully  one-half  of  the  cases. 
Inheritance  of  the  same  form  of  psychosis  is  strikingly  frequent  as 
regards  melancholia.  Females  are  more  often  affected  than  males, 
almost  in  the  proportion  of  two  to  one.  Heredity,  physical  ill-health, 
and  mental  stress  together  form  a  triad  of  factors  which  are  responsible 
for  most  cases  of  melancholia.  This  psychosis  is  observed  at  any  age. 
At  puberty  it  is  commonly  associated  with  excessive  masturbation. 
Love-affairs,  with  the  novel  stresses  incident  to  such  emotions,  may  be 
an  exciting  cause  in  adolescence.  Pregnancy,  especially  in  primiparse, 
is  a  not  infrequent  cause,  owing  to  the  emotional  strains  which  are  fre- 
quently clustered  about  this  physiological  commotion.  The  melancholia 
of  pregnancy  generally  begins  about  the  third  or  fourth  month.  Pro- 
longed lactation  may  cause  melancholia  by  inducing  a  general  debility 
and  anemia.  The  parturitional  period  of  the  puerperal  state  does  not 
produce  melancholia  so  often  as  gravidity  and  lactation.  The  psychoses 
of  parturition  are  more  commonly  of  the  nature  of  acute  hallucinatory 
paranoia.  The  melancholia  of  the  climacteric  is  due  to  the  physiological 
commotion  incident  to  this  period  of  involution  and  to  associated  ill- 
health  and  mental  strains.  In  old  age  melancholia  is  often  associated 
with  senile  involution  and  nutritional  changes  in  the  central  nervous 
system  from  cerebral  endarteritis.  Homesickness  is  a  frequent  cause  of 
melancholia.     Auto-intoxication  undoubtedly  plays  a  considerable  role 


3IELANCH0UA. 


779 


in  the  development  of  melancholia.  Occasionally  severe  forms  of  agi- 
tated melancholia  are  associated  with  chronic  alcoholism.  It  is  said 
that  northern  races  and  people  inhabiting  mountainous  regions  are 
especially  subject  to  melancholia. 

Mental  Symptoms. — The  affective  state  in  this  psychosis  varies 
from  simple  dejection,  in  which  every  thought  and  everything  in  the 
environment  of  the  patient  has  a  sorrowful  color,  to  a  state  of  profound 
depression,  in  which  the  patient  is  either  paralyzed  by  the  dreadful 
nature  of  his  concepts  or  thrown  into  a  state  of  agitated  sufiTering  asso- 
ciated with  marked  precordial  distress.  There  are  many  degrees  lying 
between  these  extremes.  This  morbid  depression  is  in  many  ways 
paralleled  by  and  analogous  to  the  conditions  of  normal  grief  in  which 
we  observe  a  varied  behavior  of  diiferent  individuals  under  the  influence 
of  distressing  emotions  ;  some  become  strangely  quiet  and  still ;  others, 
again,  make  noisy  and  agitated  demonstrations  of  their  grief.  Normal 
grief,  too,  is  often  accompanied  by  sensations 
of  choking  and  of  sinking  at  the  heart,  which 
are  similar  but  comparatively  mild  manifes- 
tations of  the  precordial  anxiety  and  dread 
of  the  psychosis.  AYe  observe  often  in 
melancholia  a  rhythmic  oscillation  of  the 
state  of  depression  during  the  day,  and  fre- 
quently from  one  day  to  another.  Thus, 
the  depression  is  at  its  height  in  the  morn- 
ing (when  suicidal  tendencies  not  infre- 
quently present  themselves),  being  followed 
by  a  recession  with  another  exacerbation 
toward  night.  Very  often  patients  sleep 
better  on  alternate  nights,  and  manifest 
intenser  emotional  depression  on  alternate 
days.  In  some  cases,  presenting  what  is 
known  as  the  apathetic  form  of  melancholia, 
the  patients  complain  that  they  have  no 
feeling  at  all ;  that  they  are  aifected  neither 
by  things  cheerful  nor  grievous,  pleasant  nor  painful ;  that  they  have 
no  longer  any  love  for  family  or  home,  or  interest  in  anything ;  that 
they  can  never  be  sad  or  glad  again.  Sensory  disturbances  are  often 
absent.  In  the  apathetic  variety  there  may  be  analgesia.  Marked 
illusions  and  hallucinations  are  observed  in  only  about  a  tenth  of  all 
cases  of  melancholia.  Where  they  are  present  in  great  number,  the 
psychosis  is  designated  as  acute  hallucinatory  melancholia.  The  pares- 
thesias in  the  region  of  distribution  of  the  vagus  are  neither  illusions 
nor  hallucinations,  but  they  may  give  rise  to  delusions  ;  they  de^iend 
probably  upon  vasomotor  disturbances.  The  melancholiac  perceives 
and  identifies  ordinary  and  special  sensations  slowly  and  with  diffi- 
culty. The  peripheral  stimuli  of  his  environment  go  unnoticed. 
When  hallucinations  are  present,  they  usually  affect  most  of  the  senses, 
and  are  terrifying  and  dreadful  in  character.  The  patient  sees  the 
flames  of  hell,  phantoms,  and  ghosts  of  dead  persons  ;  hears  voices  which 


Fig.  305  — Acute  melancholia 
passiva. 


780  3IENTAL  DISEASES. 

reproach  and  threaten  him,  or  the  sounds  of  machinery  and  other 
tortures  which  are  being  prepared  to  cut  him  up  or  mutilate  him  ;  smells 
and  tastes  horrible  things,  and  so  on. 

jSText  to  the  affect  of  depression,  the  most  noteworthy  symptom  of 
melancholia  is  the  slowing  of  the  thought  processes.  This  is  the  an- 
tithesis of  the  accelerated  flow  of  thought  noted  in  maniacal  conditions. 

The  processes  of  memory  are  retarded,  and  the  attention  of  the 
patient  difficult  to  gain.  A  minute  or  several  minutes  are  required  for 
the  answer  to  the  simplest  question.  Sometimes  no  answer  is  given  at 
all,  or  at  most  the  lips  stir  inaudibly. 

The  contents  of  the  concepts  may,  in  milder  degrees,  show  no  de- 
lusions. More  often  the  patient  attempts  to  explain  his  feeling  of 
abject  misery  and  distress  either  by  the  presence  of  some  fancied  physi- 
cal ailment  (hypochondriacal  melancholia,  with  delusions  of  having 
syphilis,  consumption,  cancer,  impotence,  incurable  disorders  of  the 
stomach,  bowels,  etc.),  or  as  the  result  of  some  sin  of  his  past  life.  To 
the  delusion  of  having  sinned  an  especial  color  is  given  by  the  character 
of  the  patient's  early  education.  Thus,  a  strong  religious  bias  gives  rise 
to  delusions  of  having  committed  the  unpardonable  sin,  of  being  doomed 
to  hell,  to  everlasting  punishment,  to  be  buried  alive,  etc.  Often  such 
delusions  are  connected  with  some  trivial  error  of  his  past  life.  For 
instance,  a  patient  of  mine  recently  told  me,  "  I  once  chloroformed  a 
dog  to  death  and  buried  him.  I  think  now  I  made  a  mistake  in  not 
making  positively  sure  that  the  dog  was  dead,  and  as  a  result  I  am 
doomed  to  be  buried  alive  also,  and  to  be  tortured  with  dreadful 
thoughts  through  eternity,  each  day  the  torture  growing  more  dreadful, 
up  to  the  decillionth  power  of  intensity." 

Patients  often  say  they  are  not  sick,  they  are  only  wicked.  They 
have  committed  sins  not  only  against  God,  but  against  society.  Not 
only  must  they  undergo  the  punishment  ordained  by  Heaven,  but  they 
must  answer  to  man  for  infringements  of  human  law.  They  are  to  be 
put  in  prison,  to  be  killed,  to  be  hung.  Thus  they  come  to  delusions 
which  are  somewhat  similar  to  persecutory  ideas  in  that  they  believe  the 
officers  of  the  law  are  after  them,  etc.  These  differ,  however,  from  the 
true  persecutory  delusions  in  which  patients  have  no  self-depreciatory 
ideas,  but  believe  themselves  to  be  the  innocent  victims  of  inimical  con- 
spiracies. Delusions  of  poverty  are  very  common,  and  especially  so  in 
senile  melancholia. 

The  conduct  of  the  melancholiac  depends  upon  the  contents  of  his 
consciousness.  In  his  expression  we  note  the  lines  of  extreme  depres- 
sion, or  of  fear  and  terror.  The  patient  with  the  delusion  of  sin  or 
poverty,  for  example,  presents  motor  inhibition.  He  sits  in  one  place 
with  head  bowed  down,  unmindful  of  what  goes  on  about  him,  indiffer- 
ent or  apathetic  to  all  questions  put  to  him,  resisting  every  attempt  to 
give  him  food  or  medicine,  or  to  dress  and  undress  him,  or  to  give  him 
exercise.  He  is  lost  in  the  contemplation  of  his  misery.  Another 
patient,  with  these  or  similar  depressed  ideas  more  accentuated,  or  with 
marked  hallucinations,  will  wring  his  hands,  tear  his  hair,  walk  or  run 
up  and    down,  bewailing    his  misfortunes,  or    seeking   to    escape    the 


MELANCHOLIA. 


781 


dreadful  fate  in  store  for  him.  In  the  first  case  the  motor  inhibition 
may  be  so  complete  as  to  make  the  patient  perfectly  immobile,  so  that 
not  a  single  voluntary  movement  is  made  ;  even  micturition  and  defeca- 
tion are  involuntary.  Such  immobility  is  generally  of  flaccid  character, 
but  sometimes  it  assumes  the  phase  of  rigidity,  a  waxy  flexibility,  or  a 


Fig.  306. — Catatouic  symptoms  in  various  psychoses  (melancholia,  general  paresis,  circular  insanity, 
primary-dementia,  etc.)  (photograph  loaned  by  Br.  Atwood,  of  Bloomingdale). 


spasmodic  resisting  rigidity  (catatonic  rigidity).  Catatonic  symptoms 
have  been  noted  in  other  forms  of  psychoses,  but  the  disorder  described 
by  Kahlbaum  under  the  name  catatonia  is  really  a  form  of  melancholia. 
Suicidal  tendencies  are  observed  in  every  type  of  melancholia,  but  es- 
pecially in  those  with  precordial  distress  and  agitation.      In  the  milder 


782 


MENTAL  DISEASES. 


degrees,  an  attempt  at  suicide  is  often  the  first  intimation  to  friends  of . 
the  actual  existence  of  insanity,  since  in  these  cases,  outside  of  the  sor- 
rowful mood  of  the  patient,  the  intellectual  processes  may  go  on  as 
before.  Cases  of  melancholia  attonita  (with  marked  motor  inhibition) 
also  often  make  attempts  at  suicide,  unexpected  explosive  attempts,  the 
result  of  the  sudden  letting  up  of  mental  and  bodily  tension.  This  has 
been  called  the  raptus  melancholicus.  Homicidal  attempts  and  violent 
assaults  are  occasional  in  melancholia.  A  melancholy  mother  kills  her 
children  to  put  them  out  of  an  unhappy  world.  Or  a  sudden  dangerous 
assault  is  made  as  an  explosion  of  motor  tension.  Hypochondriacal 
melancholiacs  may  mutilate  themselves.  Patients  with  melancholia 
have  also  been  known  to  enter  upon  alcoholic  excesses  to  drown  their 
misery  ;  this  is  especially  observed  in  periodical  melancholia.  The  re- 
fusal of  food  is  almost  the  rule  of  conduct  in  all  forms  of  melancholia. 
Sometimes  this  refusal  rests  upon  a  delusional  foundation  :  the  patient 

thinks  he  can  not  digest  his  food,  that  it 
never  passes  through  him,  that  he  is  too 
poor  to  pay  for  it,  that  he  is  too  wicked  to 
eat,  that  he  must  do  penance,  and  so  on. 
Or  he  refuses  food  with  deliberate  suicidal 
intent.  Generally,  profound  anorexia,  con- 
stipation, and  gastro-intestinal  disorders  are 
at  the  basis  of  this  refusal  to  eat. 

Physical  Symptoms. — The  pulse  is 
usually  subnormal  in  frequency,  though 
sometimes,  especially  in  agitated  forms,  ac- 
celerated. The  peripheral  arteries  are  con- 
tracted and  the  extremities  cold.  The  res- 
piration is  retarded  and  superficial,  as  a 
rule,  though  it  may  be  increased  in  the 
agitated  types.  Sleep  is  much  disordered, 
and  even  altogether  absent,  in  severe  cases. 
The  patient  emaciates  both  through  refusal 
of  food  and  because  of  disordered  digestion. 
The  gastric  juice  and  saliva  are  often  diminished  in  quantity.  The 
tongue  is  foul  and  furred,  and  obstinate  constipation  is  present.  As  a 
result  of  constipation,  elevations  of  temperature  may  be  observed,  but 
otherwise  the  temperature  is  undisturbed.  The  surface  temperature  in 
the  extremities  is  often  much  reduced.  Amenorrhea  is  frequently  in- 
duced by  melancholia  as  well  as  by  mania. 

Varieties. — As  in  the  case  of  mania,  we  distinguish  acute,  subacute, 
and  chronic  forms  of  melancholia ;  acute  and  subacute  according  to  the 
degree  and  rapidity  of  inception,  chronic  from  the  duration. 

Melancholia  jxissiva  is  a  term  used  to  describe  the  cases  with  great 
motor  inhibition  of  the  flaccid  order. 

Melancholia  attonita  designates  the  type  with  motor  tension  and 
rigidity. 

Melancholia  agitata  is  a  name  used  for  melancholia  with  motor 
excitement. 


Fig.  307. — Chronic  melancholia 
passiva. 


MELANCHOLIA.  783 

Acute  hallucincdorij  melancholia  is  the  form  accompanied  by  numerous 
illusions  and  hallucinations. 

Hi/pochotidriacal  nirlaiicholia  is  melancholia  associated  with  delusions 
as  to  physical  maladies. 

Raptm  melancJiolicus  is  a  phrase  employed  to  describe  the  furious 
outbreaks  of  violence  toward  the  patient  himself  or  others,  on  the 
sudden  cessation  of  mental  and  motor  tension. 

Catatonic  melancholia,'^  already  alluded  to,  is  not  a  distinct  type  of 
mental  disease,  but  simply  a  modification  in  the  course  of  melancholia. 
It  has  often  been  considered  as  a  special  form  of  psychosis,  and  many 
alienists  have  argued  pro  and  con.  the  question  of  its  being  a  clinical 
entity.  It  is  a  very  rare  syndrome.  A  perfectly  typical  case  is  the 
following,  observed  by  me  in  the  Hudson  River  State  Hospital : 

Case  I. — B.  R.,  female ;  age  thirty-one ;  married,  with  four 
children ;  Hebrew ;  common  education ;  born  in  United  States ; 
admitted  to  the  Hudson  River  State  Hospital  in  February,  1884  ;  no 
heredity. 

The  first  evidence  of  mental  disturbance  was  in  August,  1883,  after 
the  birth  of  her  last  child,  which  she  nursed  for  two  months,  when  she 
became  sleepless,  restless,  and  inclined  to  refuse  food.  Soon  she  devel- 
oped the  idea  that  she  would  never  recover,  began  to  bemoan  her  con- 
dition, and  said  it  was  hard  to  die  so  young.  There  was  complete 
anorexia.  She  took  no  interest  in  anything,  became  careless  of  her 
person  and  dress  and  negligent  of  everything  in  which  she  had  formerly 
been  interested.  Three  weeks  before  admission  she  became  suicidal, 
spoke  of  it,  and  attempted  to  choke  herself  and  to  cut  herself  with  glass. 
She  would  bite  her  caretakers,  and  took  every  means  possible  to  make 
away  with  herself.  Her  menstruation  was  regular.  There  was  con- 
siderable constipation.  The  case  was  regarded  as  one  of  puerperal 
melancholia. 

February  11th,  two  days  after  admission,  she  tried  to  beat  her  head 
against  the  bedstead  ;  said  some  one  was  killing  her  children  and  putting 
them  in  a  box  ;  said  arsenic  was  put  in  her  coffee  and  that  her  mother 
was  in  the  asylum ;  was  sleepless  and  had  to  be  fed  forcibly.  She 
became  rapidly  worse  during  the  next  few  days  ;  went  into  a  condition 
of  noisy  excitement,  calling  for  her  mother,  whom  she  believed  to  be  in 
the  building  ;  mentioned  her  delusions  of  poisoning,  beat  and  bruised 
herself  against  the  bedstead,  and  refused  all  food.  She  was  very  suicidal. 
Her  mouth  and  tongue  became  dry;  she  showed  symptoms  of  exhaustion 
and  was  fed  with  the  tube  for  a  considerable  period.  She  continued  to 
refuse  food,  to  resist  all  care  strenuously,  and  to  be  desperately  suicidal 
until  March  15th,  when  she  became  cataleptic,  with  marked  flexibilitas 
cerea  ;  absolutely  silent ;  noticing  nothing,  not  even  her  husband,  who 
visited  her  ;  would  swallow  food  put  in  her  mouth  ;  made  no  voluntary 
motions  ;  pulse  good  ;  bowels  moved  by  enemata,  but  began  to  wet  and 
soil  the  bed,  and  as  she  grew  stronger  was  looked  upon  as  rapidly  be- 
coming demented.     This  state  of  catalepsy  continued,  with  variations 

^  "Catatonia,"  by  Frederick  Peterson,  M.D.,  and  Charles  H.  Langdon,  M.D., 
"Proceedings  of  the  Amer.  Medico-Psychological  Assoc. , "  Baltimore,  1897. 


784  MENTAL  DISEASES. 

from  time  to  time,  for  a  month  or  more,  when  she  began  to  be  destruc- 
tive of  her  clothing,  would  strip  herself  naked,  and  was  filthy  in  her 
habits.  She  remained  in  that  condition,  seldom  uttering  a  word  for 
months,  until  about  the  last  of  November,  1884,  when  she  began  to  cry- 
out  loudly,  "Bring  me  home  to  my  children  in  New  York.  Bring 
me  home  to  my  children  in  New  York,"  reiterating  this  over  and  over 
from  morning  until  night,  and  accompanying  the  phrase  with  rhythmic 
movements  of  the  hands  and  arms  as  if  she  were  waving  them  in  the 
direction  she  wished  to  go.  There  was  a  rhythm  in  the  days,  too,  for 
every  alternate  day  she  was  quiet  in  her  chair  and  would  whisper.  This 
continued  without  variation  for  some  two  months,  during  all  of  which 
time  she  was  eating  and  sleeping  well  and  gaining  in  flesh. 

About  the  middle  of  January,  1885,  her  verbigeration  took  another 
character,  the  gesticulations  remaining  the  same.  She  began  to  recite 
all  day  long,  every  other  day,  with  great  rapidity  and  with  infinite 
variation,  in  rhymes  of  unintelligible  words,  as  follows  : 

"Moccasins,"  "Tabies,"  "Jobis," 

' '  Yoccasins, "  "  Gabies, "  "  Chobis, ' ' 

' '  Doccasins, "  "  Habies, "  "  Sobis, ' ' 

"  Crockasins,"  "Sabies,"  "Pobis," 

' '  Lockasins,  "  "  Labies, "  "  Tickater, ' ' 

"Tockasins,"  "Mabies."  "Fickater," 

' '  Jockasins, "  "  Kabies, "  "  Sickater, ' ' 

' '  Hockasins, "  "  Nobis, "  "  Lickater, ' ' 

' '  Babies, "  "  G-obis, "  "  Mickater, ' ' 

and  so  on,  ad  infinitum.  She  only  changed  to  another  word  when  the 
possibilities  of  rhyme  were  exhausted. 

She  was  mentally  confused.  AVhen  asked  why  she  made  these 
rhymes  she  said  some  one  told  her  to ;  but  this  was  probably  an  answer 
given  because  she  could  not  explain  why,  for  she  had  now  no  hallucina- 
tions or  delusions.  She  was  so  confused  that  she  did  not  feel  sure  it 
was  her  husband  who  came  to  see  her. 

A  few  months  later  she  gave  up  the  rhyming  assonances  and  returned 
to  the  old  phrase,  with  occasional  variations,  "  I  want  to  go  home  to  my 
children  in  New  York."  "  Won't  I  be  glad  when  I  get  home  to  my 
children  in  New  York."  "  What  good  times  I'll  have  when  I  get 
home  to  my  children  in  New  York  ...  to  my  cosy  home  in 
New  York  .  .  .  when  I  get  into  the  car  which  takes  me  to  my 
husband  and  children  in  New  York."  This  was  the  refrain  for  many 
months  on  alternate  days,  accompanied  as  before  with  rhythmic  gestures 
of  both  arms  in  the  supposed  direction  of  New  York.  In  the  spring  of 
1886,  on  the  quiet,  alternate  days,  she  began  to  sew.  She  steadily  im- 
proved in  flesh  and  was  looked  upon  as  in  a  state  of  dementia.  There 
was  no  appreciable  change  in  her  condition  during  the  summer.  The 
verbigeration  and  gesticulation  alternated  with  quiet  and  industrious 
days  until  the  autumn  of  1886,  when  improvement  began  to  manifest 
itself  in  every  way,  and  in  November  she  was  discharged  as  improved 
and  went  home  with  her  husband  on  trial.  There  she  recovered  per- 
fectly so  that  not  a  vestige  of  the  insanity  remains,  and  she  is  to  this  day 


MELANCHOLIA.  785 

in  full  charge  of  her  household  and  family,  as  reported  to  us  not  long 
since  by  her  husband. 

In  this  case  we  have,  first,  an  ordinary  suicidal  melancholia,  with 
delusions  of  poisoning,  the  killing  of  her  children,  etc.,  and  hallucina- 
tions of  taste  and  hearing,  and  possibly  sight,  rapidly  becoming  an 
aggravated  case  of  melancholia  agitata  of  almost  maniacal  character, 
with  a  sudden  lapse  into  a  cataleptic  condition  lasting  about  a  month, 
after  which  she  was  for  some  months  silent,  stupid,  having  to  be  dressed, 
undressed,  and  cared  for  in  every  way,  when  she  began  to  show  symp- 
toms of  verbigeration  and  rhythmic  gestures  previously  described. 
During  most  of  the  long  period  presenting  these  symptoms  she  was 
mentally  confused,  but  her  mood  was  rather  cheerful.  She  would  fre- 
quently smile  when  any  one  asked  her  why  she  talked  in  that  way, 
and  she  seemed  to  take  pleasure  in  what  she  was  constantly  reiterating. 

The  conclusions  at  which  we  arrived  in  our  paper  were  as  follows : 
I.  Catatonia  is  not  a  distinct  form  of  insanity — not  a  clinical 
entity. 

II.  There  is  no  true  cyclical  character  in  its  manifestations  ;  hence 
it  can  not  properly  be  classed  as  a  form  of  circular  insanity. 

III.  It  is  simply  a  type  of  melancholia. 

IV.  It  is  not  desirable,  therefore,  to  retain  the  name  catatonia. 

V.  The  term  "  catatonic  melancholia  "  or  "  catatonic  syndrome  " 
may  be  usefully  retained  as  descriptive  of  melancholia  with  cataleptic 
symptoms,  verbigeration,  and  rhythmic  movements,  but  should  be 
strictly  limited  to  this  symptom-complex. 

VI.  The  prognosis  in  melancholia  with  catatonic  symptoms  is  more 
grave  than  in  any  other  form. 

VII.  The  treatment  of  the  catatonic  syndrome  is  the  same  as  for  the 
other  types  of  melancholia. 

Periodical  or  intermittent  or  recurrent  melancholia  has  about  the  same 
significance  as  the  similar  designation  of  forms  of  mania. 

Other  names  are  frequently  given  to  melancholia,  such  as  senile, 
puerperal,  and  the  like,  but  they  merely  cite  some  determining  factor. 
The  fundamental  condition  is  the  same. 

Pathological  Anatomy. — As  is  true  of  mania,  there  is  also  no 
known  pathological  anatomy  for  melancholia.  It  is  a  functional  nutri- 
tional disorder  of  the  brain,  a  diminished  or  perverted  metabolism, 
supposed,  theoretically,  to  rest  upon  a  cerebral  anemia,  or,  possibly,  an 
autotoxemia. 

Course  of  the  Disease. — There  is  no  such  distinct  prodromal  stage 
in  melancholia  as  in  mania.  The  period  of  invasion  is  deliberate,  and 
the  symptoms  chiefly  manifested  at  first  are  gastro-intestinal  disorders, 
dyspepsia,  loss  of  appetite,  constipation,  accompanied  by  sensations  of 
pressure  in  the  head  or  headache,  insomnia,  and  general  malaise.  The 
depression  itself  is  the  cardinal  early  psychic  symptom.  Melancholia, 
like  all  psychic  disorders,  is  slow  in  its  progress,  and  runs  a  course  of 
from  three  to  six  months  in  the  most  favorable  cases,  but  sometimes  a 
year  or  two  or  three  elapse  before  recovery  takes  place.  Ordinarily, 
recovery  is  gradual,  and  is  frequently  accompanied  by  a  species  of  reactive 
50 


786  MENTAL   DISEASES. 

exaltation.  Occasionally  recovery  is  quite  rapid.  In  women  the  ap- 
proach of  convalescence  is  indicated  by  a  return  of  the  menstrual  fmic- 
tion.  In  all  cases  improvement  in  physical  health  accompanies  conva- 
lescence. 

^Melancholia  terminates  in  recovery  (ninety  per  cent.),  in  recovery 
with  defect,  in  death,  in  secondary  dementia,  in  chronic  melancholia,  or 
in  a  secondary  paranoia. 

While  the  majority  of  cases  of  melancholia  recover  completely,  there 
are  a  few  in  which,  despite  apparent  recovery,  accurate  investigation 
reveals  a  defect  of  the  intellectual  powers,  a  difficulty  of  entertaining 
complicated  conceptions  and  judgments,  which  may  easily  escape  the 
notice  of  the  patient's  friends.  In  a  very  small  number  of  cases  the 
mind  becomes  so  enfeebled  that  the  condition  becomes  a  veritable 
secondary  dementia,  in  which  we  discover  vestiges  of  the  antecedent 
melancholia  in  the  shape  of  automatic  phrases  and  movements  and 
expressions  of  a  depressed  color,  yet  without  any  actual  affective  mood. 
The  patients  become  negligent  of  person  and  dress  in  the  extreme,  even 
filthy  in  their  habits. 

A  chronic  persistence  of  the  melancholic  symptoms  is  rather  more 
frequent  as  a  termination  than  secondary  dementia.  In  chronic  melan- 
cholia we  observe  symptoms  of  either  the  simple  depressed  or  the  agitated 
form  with  which  the  disorder  began,  but  these  symptoms  are  diminished 
in  intensity.  The  precordial  distress  disappears.  Some  of  their  delu- 
sions, movements,  and  verbal  expressions  become  automatic,  as  in  cases 
accompanied  by  dementia.  Special  forms  of  chronic  melancholia  are 
the  insanity  of  negation  and  insanity  with  transformed  or  duplicated  per- 
sonality.    These  are  very  apt  to  develop  upon  a  hypochondriacal  basis. 

A  termination  of  melancholia  in  a  paranoid  condition  (paranoia 
secondaria  melancholica)  while  rare,  is  rather  more  frequent  as  a  sequel 
of  melancholia  than  of  mania.  In  these  cases  there  are  numerous 
hallucinations,  and  a  cluster  of  delusions,  religious,  persecutory,  or  hypo- 
chondriacal, which  gradually  become  systematized  to  a  greater  or  less 
degree.  About  half  of  such  cases  recover  ultimately,  the  remainder 
passing  into  a  condition  of  dementia. 

Death  in  cases  of  melancholia  is  due  to  suicide,  marasmus,  visceral 
disorders,  diarrhea,  pneumonia,  etc.  A  ver^^  large  number  of  long- 
standing cases  die  of  tuberculosis. 

Diagnosis. — One  of  the  most  common  conditions  with  which  melan- 
cholia may  be  confounded  is  a  depressed  stage  of  general  paresis.  The 
chief  points  of  distinction  are  the  actual  intellectual  defect  nearly 
always  demonstrable  in  paralytic  dementia,  and  especially  the  physical 
symptoms  of  paresis,  pupillary  changes,  faciolingual  tremor,  character- 
istic speech,  greatly  exaggerated  or  lost  deep  reflexes,  and  one-sided 
facial  weakness.  The  depression  of  the  paralytic  dement  is  superficial. 
His  melancholy  delusions  are  ordinarily  distinguislied  by  their  inordinate 
and  preposterous  character,  by  the  monstrosity  of  their  contents.  In 
addition  to  these  points,  the  signs  of  previous  syphilis  and  the  age  from 
tliirty-five  to  fifty  years  would  have  some  corroborative  value  in  the 
diagnosis  of  general  paresis. 


3IELANCH0LIA.  787 

A  primary  dementia  may  be  misinterpreted  as  a  stuporous  form  of 
melancholia.  In  primary  dementia,  intellectual  defect  is  the  cardinal 
symptom  ;  in  apathetic  melancholia  there  is  no  intellectual  defect,  and 
the  apathy  is  often  clearly  accompanied  by  painful  aifects  from  time  to 
time. 

Hallucinatory  paranoia  with  depressive  hallucinations  may  be  con- 
fused with  melancholia.  In  hallucinatory  paranoia  we  have  two  vari- 
eties, a  stuporous  and  an  agitated  form,  and  these  have  some  analogy 
to  melancholia  attonita  and  melancholia  agitata.  The  want  of  fixity 
and  systematization  of  delusions  in  melancholia  is  to  be  remembered. 
The  history  of  the  patient  will  often  reveal  whether  the  depression  is 
primary  or  not.  But  the  differentiation  is  often  difficult,  and  especially 
so  between  hallucinatory  melancholia  and  hallucinatory  paranoia.  Long 
and  careful  study  of  the  case  during  its  progress  may  be  requisite  for 
an  absolute  diagnosis. 

Senile  dementia  may  simulate  a  melancholia  with  stupor.  The  age 
and  the  intellectual  defect  present  will  be  in  favor  of  the  former.  But 
senile  melancholia  is  particularly  apt  to  present  an  apparent  defect  of 
intellect. 

The  possibility  of  the  melancholia  being  a  phase  of  a  circular  in- 
sanity is  also  to  be  borne  in  mind. 

There  are  instances  of  such  a  disorder  as  typhoid  fever  being  tem- 
porarily mistaken  for  melancholia,  but  naturally  the  course  of  the 
temperature  and  the  character  of  the  stupor  or  delirium  would  soon 
correct  such  an  error. 

Prognosis. — The  facts  which  will  shape  prognosis  are  to  be  drawn 
from  what  has  been  said  previously  in  regard  to  the  course  and  termina- 
tion of  melancholia.  In  simple  forms  of  the  disorder  the  prognosis  is 
very  favorable  indeed,  and  recovery  can  be  predicted  in  from  three  to 
six  months.  In  the  agitated  type  the  outlook  is  less  favorable,  and  in 
hallucinated  and  apathetic  forms  still  less  so.  The  catatonic  variety  is 
the  least  favorable  of  all  as  regards  recovery. 

Treatment. — The  first  consideration  in  the  treatment  of  acute 
melancholia  is  isolation.  Separation  from  the  friends  and  i;elatives  and 
removal  from  the  environment  in  which  the  psychosis  has  developed  are 
of  the  greatest  importance.  With  familiar  faces  and  objects  about  him, 
and  with  his  kin  offering  their  help  and  sympathies,  the  keenest  realiza- 
tion of  his  condition  is  brought  home  to  the  melancholiac.  He  feels 
among  them  all  the  more  deeply  a  sense  of  his  incapacity,  of  his 
inability  to  fulfil  the  ordinary  duties  and  demands  of  his  usual  daily  life. 
Whether  the  patient  is  to  be  isolated  by  commitment  to  an  asylum 
depends  upon  several  circumstances  :  his  means ;  the  intensity  of  his 
malady  ;  the  presence  of  suicidal  tendencies.  There  are  very  mild  cases 
in  which  moderate  travel,  a  sojourn  in  the  country  with  a  nurse,  a  few 
months  at  the  house  of  some  country  physician  or  in  a  small  private 
asylum,  will  result  in  recovery.  But  the  responsibility  for  such  a 
course  must  rest  with  the  physician  who  advises  it,  and  he  must  keep  in 
mind  the  danger  of  suicide  in  even  the  mildest  type  of  melancholia. 
Not  a  few  lives  have  been  needlessly  sacrificed  by  the  inexpertness  of 


788  MENTAL   DISEASES. 

the  consulting  physician.  Besides  extreme  watchfuhiess  on  the  part  of 
the  caretaker,  who  is  not  to  leave  the  patient  alone  either  night  or  day, 
a  modified  or  a  complete  rest-cure  is  to  be  undertaken.  For  mild 
decrees  of  melancholia  rest  in  bed  from  6  p.  m.  until  noon  of  the  next 
dav,  with  plenty  of  out-of-door  exercise  during  the  remainder  of  the  after- 
noon, is  most  commendable.  For  the  more  severe  types,  continual  rest 
in  bed  is  requisite.  The  food  should  naturally  be  easily  digestible 
and  assimilable,  and  the  patient  should  be  made  to  take  considerable 
quantities  of  milk  and  milk  products  (koumiss,  matzoon,  somal,  etc.), 
raw  eggs,  meat-juices,  and  stimulants,  when  these  are  indicated. 
Massage  and  general  faradization  (sufficiently  strong  to  contract  the 
muscles)  are  useful  to  take  the  place  of  exercise  in  cases  taking  the 
complete  rest-cure.  Constipation  should  be  regularly  counteracted  by 
abdominal  massage,  frequent  purgation,  glycerin  injections,  enemata, 
etc.  This  is  particularly  necessary  in  cases  suspected  of  suffering  from 
auto-intoxication.  In  these  cases,  too,  gastro-intestinal  antiseptics — such 
as  salol,  gr.  v,  or  beta-naphtol,  gr.  v — should  be  administered  thrice 
daily  two  hours  after  eating.  Ten  grains  of  glycerophosphate  of  soda 
in  a  large  glass  of  hot  water  a  half  hour  before  eating  is  also  a  useful 
remedial  agent  in  melancholia.  For  sleeplessness  the  prolonged  warm 
bath  or  the  hot  wet-pack  is  to  be  recommended  ;  in  the  event  of  their 
failure  to  induce  a  few  hours'  sleep  in  each  twenty-four  hours,  sleep- 
producing  drugs  are  necessary.  Sulphonal  and  trional,  of  each  ten  grains, 
given  together  at  bedtime  with  a  glass  of  hot  milk  or  a  cup  of  hot 
soup,  are  efficient  in  mild  cases. 

The  opium  treatment  is  a  sort  of  specific  for  melancholia,  especially 
when  there  are  agitation  and  precordial  anxiety  and  distress.  Beginning 
with  a  medium  dose  three  or  four  times  a  day,  we  gradually  increase  it  as 
required.  Laudanum — the  solid  extract — or  codein  may  be  administered 
by  mouth.  When  employed  hypodermatically,  which  is  usually  best,  the 
watery  extract  of  opium  is  used.  It  is  preferable  to  administer 
morphin  only  in  the  most  aggravated  cases,  and  in  these  it  may  often 
be  advantageously  combined  with  hyoscin,  hyoscyamin,  or  cluboisin. 
It  is  needless  to  say  that  the  opium  treatment  should  not  be  made  known 
to  the  patient,  and  it  is  carried  out  with  more  safety,  as  regards  the  forma- 
tion of  a  habit,  when  the  patient  is  in  an  institution.  As  the  patient 
improves,  the  opium  is  gradually  reduced  until  it  can  be  finally  cut  off 
altogether.  Opium  does  not  increase  constipation,  except  possibly  for  a 
few  days  when  first  employed  ;  it  seems  actually  in  many  cases  to 
diminish  it.  Sometimes,  indeed,  we  need  to  treat  diarrheas  that  arise  as 
a  result  of  the  opium  treatment. 

As  soon  as  it  becomes  possible  to  do  so,  physical  occupation  should 
be  begun  and  encouraged.  A  life  out-of-doors,  made  interesting  by 
different  kinds  of  amusement  or  labor ;  walks,  field  studies  in  natural 
history  (botany,  ornithology,  geology,  physical  geography,  etc.),  golf, 
bicycling,  agriculture,  and  gardening — all  of  these  have  their  place 
among  the  remedial  agents  at  the  disposition  of  the  discerning  and  judi- 
cious physician. 


CIRCULAR  INSANITY.  789 


CHAPTER  VIII. 
CIRCULAR  INSANITY, 

Synonyms. — Alternating  Insanity ;   Insanity  of  double  form  ;   Insanity  of  double 

phase  ;  Cyclic  psychosis. 

Definition. — Circular  insanity  is  a  form  of  psychosis  characterized 
by  an  alternation  of  states  of  mania  and  melancholia.  There  are 
varieties  of  circular  insanity  which  will  be  discussed  later,  but  the 
maniomelancholic  alternation  is  the  distinguishing  feature  of  all  types 
of  this  cyclic  psychosis. 

Etiology. — Heredity  plays  an  especially  significant  part  in  the 
causation  of  circular  insanity  (sixty  per  cent.).  Not  only  do  we  find  in 
the  family  history  of  the  majority  of  these  cases  hereditary  equivalents 
of  different  kinds,  but  direct  inheritance  of  this  particular  variety  of 
mental  disorder  is  strikingly  frequent. 

Many  degenerates  exhibit  a  tendency  to  an  alternating  variation  of 
mood.  Sometimes  they  are  depressed  and  sometimes  cheerful.  It  is 
probable  that  this  oscillation  of  moods  in  an  individual  with  strong 
hereditary  taint  may  be  the  rudimentary  foundation  upon  ^vhich  the 
superstructure  of  a  circular  insanity  is  subsequently  laid. 

Among  special  factors  which  tend  to  develop  cases  of  acquired  cir- 
cular insanity  are  trauma  to  the  head,  alcoholism,  hysteria,  and  epilepsy. 
The  exciting  causes  are  physical  and  moral,  such  as  have  been  described 
in  the  chapter  on  General  Etiology.  Circular  insanity  is  much  more 
common  in  women  than  in  men,  the  proportion  being  about  four  to  one. 
Many  cases  develop  about  the  age  of  puberty,  and  nearly  all  before  the 
age  of  thirty  years.  The  frequency  of  this  type  of  psychosis  as  com- 
pared with  other  forms  has  not  yet  been  determined.  It  is  only  recently 
that  it  has  begun  to  be  classified  as  a  distinct  type  in  our  asylum  statis- 
tics. Thus,  the  report  of  the  Commission  in  Lunacy  of  New  York  State 
shows  but  ninety-six  cases  of  circular  insanity  in  nearly  forty  thousand 
admissions  between  October  1, 1888,  and  October  1,  1896,  but  the  type 
had  been  recognized  in  the  reports  required  from  the  asylums  for  only 
about  a  year  of  that  time.  It  is  difficult,  therefore,  to  arrive  at  any 
certain  conclusion,  but  the  best  authorities  agree  that  five  and  perhaps 
more  cases  of  alternating  insanity  will  be  found  among  every  hundred 
insane  patients. 

Symptomatology. — The  symptoms  will  vary  at  any  given  time 
according  to  the  phase  which  the  disorder  has  reached  at  the  time  of 
examination — the  phase  of  depression  or  the  phase  of  exaltation.  The 
melancholic  period  may  present  any  one  of  the  forms  of  melancholia 
described  in  another  chapter,  from  a  simple  depressed  condition,  scarcely 
distinguishable  from  the  normal  state  of  the  patient,  to  the  most  pro- 
nounced melancholic  syndrome.  In  some  cases  we  have  melancholia 
simplex,  in  others  the  hallucinatory  variety  ;  in  some  the  agitation,  in 


790 


MENTAL   DISEASES. 


others  stupor  and  catatonia.  When,  in  any  given  case,  the  melancholic 
phase  recurs  again,  it  is  prone  to  wear  the  same  features  as  in  the  first 
attack.  Thus,  mild  depression  or  simple  melancholia,  melancholia 
agitata,  or  melancholia  attonita  may  reappear  again  and  again  as  the 
cvcle  returns,  with  the  same  phase  and  character  over  and  over  again. 
While  this  is  true  in  the  majority  of  cases  of  circular  insanity,  it  is  not 
always  so,  for  occasionally  the  recurring  melancholia  changes  its  type  in 
the  various  sequences.  As  intimated  in  the  chapter  on  Melancholia, 
there  is  often  a  species  of  reactive  exaltation  in  the  convalescent  stage 
of  the  disease,  and  occasionally  this  reaction  becomes  so  accentuated 
as  to  develop  a  maniacal  condition,  so  that  we  have  presented  to  us  a 
picture  very  like  that  of  an  alternating  insanity. 

Like  the  melancholic  ])hase,  the  maniacal  period  of  circular  insanity 


Fig.  308. — A  case  of  circular  iusauity,  photographed  first  in  maniacal  or  exalted  phase,  and  some  months 
later  in  the  melancholic  phase  (Dr.  Atwood). 


may  vary  in  character  from  a  condition  of  mild  exhilaration  and  exalta- 
tion to  the  severest  types  of  maniacal  excitement  and  incoherence.  As 
in  the  depressed  period,  there  is  the  same  tendency  of  the  maniacal 
phase  in  its  recurrences  to  present  regularly  the  identical  features  of 
former  attacks,  though  there  are  also  exceptional  instances  here  where 
subsequent  outbreaks  wear  a  different  maniacal  aspect. 

In  the  chapter  on  Mania  is  made  mention  of  the  fact  that  the  con- 
valescence from  that  psychosis  is  not  infrequently  characterized  by  a 
reactive  depression,  a  lacrymose  irritability.  In  some  instances  this 
may  attain  to  the  degree  of  a  true  melancholia,  and  thus  place  before 
us  a  cycle  similar  to  that  of  an  alternating  insanity. 

Ordinarily  we  recognize  two  degrees  of  intensity  in  circular  insanity 
— one  in   which  both  the  mania  and  melancholia  are  mild,  and  one  in 


CIRCULAR   INSANITY. 


791 


which  both  the  mania  and  melancholia  are  severe.  But  there  are 
mixed  types,  in  which  the  mania  may  be  mild  and  the  melancholia 
severe,  or  vice  versa. 

Mild  types  of  circular  insanity — instances  in  which  both  the  depressed 
and  exalted  phases  are  so  moderate  in  degree  as  not  to  permit  of  com- 
mitment to  an  asylum — are  not  infrequently  met  with  by  the  practi- 
tioner, and  they  are  often  difficult  cases  to  handle  properly.  Thus,  I 
have  in  mind  two  brothers,  now  over  fifty  years  of  age,  wdio  are  both 
afflicted  with  circular  insanity,  manifested  in  a  form  very  distressing  to 
the  relatives.  A  description  of  one  will  describe  the  other,  and  not 
only  him,  but  many  other  similar  cases  : 

E.,  male,  aged  fifty-four,  single,  with  hereditary  taint,  has  for  many 
years  been  subject  to  alternating  attacks  of  depression  and  exaltation. 
I  have  seen  and  examined  him  in  both  phases.  There  is  little,  if  any, 
discernible  interval,  but  a  gradual  merging  of  one  phase  into  the  other. 


Mental  State 


_/teute 
2)etino/isJka/tuz- 


jJeide/l^ania, 


J)  imple 


'epression- 


yteuie 
.Ateta/ictioticL, 


A^eianeAolicL. 


(fan 


Fd. 


Meh4£ 


Ma 


'ay 


\ 


c/w 


duly  j4iiff. 


I 


Sept. 


Oct 


Ml 


Lee 


Fig.  309. — Scheme  of  course  of  disease  in  periodical  circular  insanity. 


The  depressed  period  lasts  for  from  three  to  six  months.  In  this,  his 
expression  is  dejected  ;  he  feels  that  life  is  a  failure,  that  he  can  not  live 
long.  He  consults  various  physicians  for  different  maladies  which  he 
thinks  may  account  for  his  general  malaise.  He  can  not  concentrate 
his  mind  on  anything,  can  not  read  or  write  letters  ;  refuses  to  transact 
the  most  necessary  business  in  connection  with  his  estate.  He  talks 
little,  and  broods  over  the  mistakes  and  follies  committed  in  the  exalted 
phase  of  his  disorder.  He  is  rather  suspicious  and  distrustful  of  his 
family.  Sometimes  he  is  inclined  to  put  an  end  to  his  misery  by  suicide. 
Liittle  by  little  this  weight  of  depression  begins  to  lighten,  and  he  passes 
insensibly  into  a  condition  in  which  he  begins  to  feel  himself  rejuvenat- 
ing. Life  takes  on  a  little  rosier  color ;  his  malaise  vanishes,  and  a 
sense  of  well-being  begins  to  infuse  itself  through  his  body.  His  ex- 
pression changes  from  the  fixed  look  of  deep  dejection  to  one  of  cheer- 
ful variability.  In  the  place  of  quiet  brooding  we  note  an  awakening 
interest  in  things   about  him.      He  begins  to  talk  vivaciously,  to  be 


792  MENTAL  DISEASES. 

facetious  and  jolly,  to  write  letters  to  his  friends,  to  make  frequent 
social  calls,  to  take  up  the  threads  of  affairs.  He  discards  the  doctors, 
for  his  health  and  strength  were  never  better.  He  takes  up  some  of 
his  old  hobbies,  one  of  which  is  the  collection  of  antiques,  arms,  plate, 
furniture,  pictures,  and  specimens  of  ceramic  art.  He  spends  money 
freely,  rather  too  lavishly.  His  collections  are  gathered  together  in 
storage  warehouses,  clubs,  his  own  home,  and  the  houses  of  his  friends. 
He  becomes  extravagant  and  wasteful ;  enters  on  great  schemes  of 
money-making,  in  which  he  becomes  interminably  entangled  and 
meets  with  financial  losses.  His  friends  expostulate,  and  he  becomes 
irritable  and  angry.  He  leaves  them,  to  live  in  hotels.  He  buys  a 
pair  of  fast  horses  and  takes  a  drive  of  several  weeks  all  over  the 
country  for  hundreds  of  miles  around.  He  grows  boisterous  in  his  con- 
versation, neglectful  of  the  ordinary  courtesies  and  civilities  of  social 
life,  is  lavish  in  his  invitations,  becomes  a  little  excessive  in  drinking, 
is  restless  both  night  and  day,  travels  from  one  city  to  another  on  the 
most  trivial  and  eccentric  errands.  He  sleeps  little.  Endeavors  on 
the  part  of  relatives  to  check  the  anarchy  of  his  conduct  bring  from 
him  threats  of  suits  and  of  personal  violence,  and  letters  which  are 
quarrelsome,  offensive,  even  profane.  With  all  this,  there  is  no  intel- 
lectual defect.  He  never  has  actually  attempted  any  overt  act  which 
would  put  him  under  the  control  of  the  law,  or  aid  in  his  commitment 
to  an  asylum  to  save  the  dissipation  of  his  energies  and  the  waste  of 
his  property.  Any  jury  would  discharge  him,  for  his  conversation 
would  show  good  memory,  active  intelligence,  keen-witted  replies  to 
all  questions.  Step  by  step  this  stage  of  exaltation  begins  to  pass 
away.  He  sinks  nearer  to  his  normal  level,  resumes  a  more  natural 
conduct  toward  his  family  and  friends,  until  again  the  depressive  ele- 
ments reappear  in  his  mental  condition.  Each  stadium  lasts  for  from 
three  to  six  months,  so  that  the  cycle  fills  about  one  year. 

Varieties. — There  are  two  main  varieties  of  circular  insanity.  One 
is  a  true  circular  insanity  in  which  the  phases  follow  each  other  in  a 
perfect  cycle  thus :  mania,  melancholia,  mania,  melancholia,  mania,, 
melancholia,  and  so  on.  The  other  type  is  one  in  which  there  is  n 
certain  periodicity  of  the  maniomelancholic  attacks  as  follows  :  manin, 
melancholia,  interval,  mania,  melancholia,  interval,  mania,  melancholia, 
interval,  etc.  Most  cases  can  be  catalogued  under  one  of  these  two 
headings,  but  there  are  deviations  which  do  not  exactly  conform  to  these 
well-defined  types,  and  some  authors  have  attempted  to  make  further, 
but  it  seems  to  me  unnecessary,  subdivisions,  upon  the  basis  of  varia- 
tions in  the  length  of  interval  and  irregularities  in  the  sequence  of  the 
phases. 

Pathological  Anatomy. — Autopsies  have  failed  to  reveal  any  im- 
portant macroscopic  or  microscopic  changes  in  the  brain  in  circular 
insanity.  Such  autopsies  as  I  have  been  able  to  find  recorded  were  made 
upon  patients  at  an  age  which  would  naturally  reveal  some  conditions 
incident  to  senile  involution,  and  these  morbid  conditions  may  or  may  not 
have  had  relation  to  the  mental  state  of  the  patient  during  life.  The  best 
that  we  can  say,  then,  is  that,  so  far  as  we  know,  there  is  no  anatomical 


CIRCULAR  INSANITY. 


793 


basis  as  yet  discovered  for  circular  insanity.  Disordered  nutrition — 
either  insufficience  or  perversion  of  metabolism — probably  underlies  the 
manifestations  of  this  psychosis. 

Course  of  the  Disease. — In  some  patients  circular  insanity  has 
its  inception  in  the  melancholic  period,  and  in  others  it  begins  with 
the  maniacal  phase.  Usually  the  initial  stadium  is  melancholia.  The 
transition  from  the  depressed  to  the  excited  phase  and  vice  versa  is 
sometimes  astonishingly  sudden.  The  period  of  transformation  may 
occupy  but  an  hour  or  even  less.  In  most  cases  the  merging  of  one 
period  into  the  other  is  very  gradual.  Another  and  extremely  rare 
mode  of  transition  is  by  successive  alternations  of  depression  and  exalta- 
tion, an  oscillating  or  rhythmic  transformation.  Still  another  method 
of  change  is  by  means  of  a  lucid  interval,  brief  or  long,  between  the 


Mental  State  Jan-  Feb   Mek  ApL  May  June  July  Jug.  SepL  Oet  Noi/.  Dee. 

J/,cute 
DehnousM'^'-ct- 

JeuteAfania-                               \     \                                     /     \ 

,1                                   1       \ 

Jimpte                                           1           \                                        1 
Srattatton.                                     '                                                   y              \ 

i^'-^~r^J-Ln±Ull ,.      ,                 J                     \ [_                  \ 

Simple'bepressm  \                      '                 i                           i                \ 

M/an^/ioticL             \           \                     \                   '                     \ 

^pit<2.ta~- 

Fig.  310.— Scheme  of  course  of  disease  in  continuous  circular  insanity. 


alternating  phases,  thus  :  mania,  interval,  melancholia,  interval,  mania, 
interval,  melancholia,  interval,  etc. 

There  is  extreme  variability  in  the  duration  of  the  maniomelan- 
cholic  cycles.  Sometimes  they  exhibit  great  irregularity  of  interval, 
from  a  few  days  to  a  year  or  more.  Sometimes  the  maniacal  phase 
lasts  one  day  and  the  melancholic  one  day,  so  that  the  cycle  is  com- 
pleted in  two  days.  In  other  cases,  again,  the  cycle  is  completed  in  two 
weeks,  or  a  month,  or  a  year.  Where  alternation  is  completed  in  short 
periods,  there  is  a  tendency  to  great  regularity.  Usually  the  melancholy 
phase  lasts  longer  than  the  maniacal. 

Diagnosis. — It  is  impossible  to  make  a  certain  diagnosis  of  circular 
insanity  unless  at  least  one  maniacomelancholic  or  melancholicomania- 
cal  cycle  has  been  observed.  If,  in  a  patient  appearing  to  have  an 
ordinary  melancholia  or  an  ordinary  mania,  there  should  be  episodic 
oscillations  of  depressed  and  exalted  emotions  (as  is  sometimes  the  case 
in  either  phase  of  the  cycle  of  circular  insanity),  then  we  are  justified  in 
entertaining  a  suspicion  of  alternating  insanity.    Even  when  an  apparent 


794  MENTAL   DISEASES. 

cycle  is  brought  to  our  attention  in  a  case  of  insanity,  it  is  not  well  to 
conclude  too  quickly  that  we  are  dealing  with  circular  insanity,  for  the 
reactive  phenomena  of  mania  and  melancholia  just  referred  to  may 
closely  simulate  the  more  serious  disorder.  The  greater  the  intensity  of 
the  second  phase  in  such  cases,  the  greater  the  presumption  of  circular 
insanity. 

There  is  occasionally  danger  of  confounding  a  periodic  mania  or  a 
periodic  melancholia  with  circidar  insanity,  especially  if  their  reactive 
phases  are  notable.  Naturally,  if  the  reactive  phases  are  very  pronounced, 
a  diagnosis  of  circular  insanity  would  be  justifiable. 

General  paralysis  occasionally  presents  cyclical  phases  analogous  to 
those  of  alternating  insanity,  but  the  physical  symptoms,  the  mental 
enfeeblement,  and  the  preposterous  delusions  of  the  expansive  periods  of 
paralytic  dementia  will  ordinarily  insure  a  correct  diagnosis. 

Prognosis. — Circular  insanity,  though  made  up  of  two  of  the  most 
curable  of  mental  disorders,  is,  curiously  enough,  itself  among  the  most 
incurable.  A  patient  seldom  recovers.  The  disorder  runs  a  long 
course  over  years  of  time,  terminating  ultimately  in  dementia. 

Treatment. — All  cases  of  circular  insanity  are  best  treated  in  an 
asylum  in  order  to  prevent  suicide  in  the  melancholic  phase,  and  vio- 
lence, excesses,  and  riotous  extravagance  in  the  maniacal  period.  Un- 
fortunately, it  is  not  always  possible  to  protect  the  patient  by  this 
means,  since  juries  are  prone  to  allow  every  man  his  freedom,  no  mat- 
ter how  dangerous  to  himself  or  others,  so  long  as  he  does  not  behave 
as  a  raving  maniac  before  them.  Even  in  the  intervals  of  lucidity  it  is 
better  for  the  patient  to  be  under  medical  supervision  in  some  institu- 
tion, with  the  hope  that  the  disorder  may  be  arrested  and  future  cycles 
prevented  or  postponed  by  the  treatment.  This  treatment  is  based 
upon  the  principles  described  in  the  chapter  on  Treatment  and  in  the 
chapters  on  Mania  and  Melancholia. 

The  rest-cure  and  hydrotherapy  are  recommended  for  both  phases 
of  the  cycle.  Hyoscin,  hyoscyamin,  and  duboisin  (gr.  y^^q  ^^  E^'  to") 
are  useful  in  the  excited  stage,  and  the  opium  treatment  in  the  depressed 
stage. 


CHAPTER   IX. 
EPILEPTIC  INSANITY. 

Some  ten  per  cent,  of  all  epileptics  become  insane.  Hence  the 
epileptic  neurosis  in  an  individual  renders  him  about  thirty  times  more 
liable  to  insanity  than  if  he  were  normal.  The  psychoses  to  which  the 
epileptic  is  subject  vary  extremely  in  character.  It  is  my  aim  to  give 
here  a  brief  review  of  these.  I  shall  not  consider  under  this  heading 
forms  of  mental  disorder  in  which  epilepsy  or  repeated  epileptiform 


EPILEPTIC  INSANITY.  795 

convulsions  make  their  appearance  in  conjunction  with  the  psychic  dis- 
turbance as  the  result  of  a  common  cause  (general  paralysis,  chronic 
alcoholism,  epileptic  idiocy,  paralytic;  idiocy,  etc.),  but  shall  limit  myself 
to  the  class  of  insanities  induced  by  the  epilepsy.  It  is,  first  of  all, 
necessary  to  dwell  for  a  moment  upon  some  of  the  ordinary  features  of 
epilepsy,  apart  from  the  familiar  phenomenon  of  muscular  convulsion. 
The  epileptic  is  subject  to  peculiar  symptoms,  which  are  looked  upon 
as  the  equivalents  of  convulsive  seizures.  Among  these  are  sudden 
brief  losses  of  consciousness.  The  consciousness  may  be  merely  clouded 
or  completely  lost.  There  may  be  no  perceptible  concomitant  symp- 
toms. On  the  other  hand,  the  defect  of  consciousness  may  be  accom- 
panied by  some  pallor  of  the  face,  a  fixity  of  the  eyes,  or  a  partial 
local  spasm  or  movement  (strabismus,  stammering  of  a  few  words, 
grimaces,  lifting  the  arm,  bowing  movement  of  the  body,  turning  of 
the  head,  etc.).  The  disorder  of  consciousness  may  be  associated  with 
an  automatic  dream-state,  similar  to  somnambulism,  in  which  compli- 
cated impulsive  movements  take  place  (automatic  continuance  of  acts 
begun  before  the  seizure,  purposeless  running,  undressing,  etc.).  Ver- 
tiginous attacks  may  be  the  equivalent  of  convulsions.  The  aura  of  an 
epileptic  attack  may  be  in  the  form  of  a  hallucination.  A  study  of 
the  psychology  of  epileptics  in  general  gives  us  a  sort  of  composite 
picture,  to  which  all  of  these  patients  conform  more  or  less  closely. 
The  mental  attitude  of  the  epileptic  is  due  to  a  variety  of  circumstances. 
In  the  first  place,  he  has  a  consciousness  of  the  dreadful  nature  of  his 
malady.  He  is  in  a  state  of  expectant  attention  as  regards  the  sudden 
blackness  and  prostration  which  are  to  strike  him  unawares  at  any 
time,  in  any  place,  like  the  lightning  from  a  clear  sky.  He  can  never 
share  the  social  pleasures  of  his  fellows.  The  schools  are  not  open  to 
such  as  he.  When  he  becomes  old  enough  to  work,  he  finds  that  no  one 
wishes  to  employ  him.  Every  avenue  of  education,  every  trade  and 
calling,  every  road  to  mental  progress,  is  barred.  He  is  a  social  out- 
cast, an  object  of  commiseration,  a  burden  to  his  friends,  perhaps  a 
family  blemish  to  be  kept  concealed.  The  doctor  is  called  in,  and, 
taking,  as  a  rule,  a  hopeless  view  of  the  case,  abandons  him  to  the 
mercy  of  the  bromids,  which  further  his  mental,  physical,  and  moral 
degradation.  In  this  way  the  epileptic  character  is  evolved.  It  con- 
sists of  a  mixture  of  melancholy,  hypochondriasis,  emotional  irritabil- 
ity, moroseness,  distrust,  misanthropy,  mental  apathy,  and  dullness, 
often  combined  with  morbid  religious  tendencies  and  modified  by  patho- 
logical psychic  conditions  incident  to  the  ravages  of  the  disease  itself. 
These  pathological  mental  states  vary  from  the  peculiar  psychic 
equivalents  just-  described  to  the  actual  psychoses  of  divers  forms 
now  to  be  detailed.  Epileptic  insanity  is  chiefly  a  progressive  psychic 
deterioration  terminating  in  dementia.  But  the  progressive  degenera- 
tion is  frequently  marked  by  episodic  outbreaks  of  psychoses  under 
various  forms.  Among  these  are  transitory  hallucinatory  and  stupor- 
ous disorders  and  chronic  epileptic  psychoses  (under  any  form,  such  as 
mania,  melancholia,  circular  insanity). 

Psychic  Degeneration  of  Epileptics. — As  is  well  known,  severe 


796  MENTAL  DISEASES. 

epileptic  attacks  are  ordinarily  followed  by  a  somnolent  and  stuporous 
condition  lasting  from  an  hour  or  two  to  several  days.  The  frequent 
repetition  of  such  attacks  tends  to  render  complete  recovery  from  such 
mental  torpor  more  and  more  difficult.  As  a  consequence,  we  observe  a 
gradual  weakening  of  the  intellectual  processes.  The  flow  of  ideas  is 
retarded  and  the  expression  of  such  ideas  along  motor  lines  becomes 
sluggish ;  the  speech  especially  has  a  characteristic  slowness ;  atten- 
tion is  diminished  and  memory  impaired  ;  the  concepts  and  judgments 
are  built  up  with  ever-slackening  activity.  In  this  way  the  epileptic 
may  sink  gradually  into  a  deepening  simple  dementia.  In  some  cases 
the  concepts  attended  with  ethical  feelings  vanish  first,  and  to  so 
striking  an  extent  that  acts  of  violence,  cruelty,  brutality,  and  crime  are 
committed  without  a  single  inhibitory  effort  or  a  shadow  of  remorse. 
These  acts  often  have  an  impulsive  character. 

An  excessive  irritability  of  temper  is  a  phase  of  epileptic  psychic  de- 
generation. The  most  trivial  incidents  may  give  rise  to  outbursts  of 
anger  and  even  of  overwhelming  fury. 

The  natural  hypochondriacal  depression  of  many  epileptics  is  fre- 
quently much  exaggerated,  giving  rise  to  a  sort  of  melancholia  colored 
by  mental  enfeebleraent,  and  by  suspicion,  distrust,  misanthropy,  and 
moroseness. 

Occasionally,  in  the  midst  of  this  progressive  deterioration  of  mind, 
imperative  ideas  and  acts  manifest  themselves,  and  delirious  states 
appear  with  dreadful  hallucinations  and  delusions  of  persecution 
(paranoia-like  outbreaks). 

These  are  the  marks  which  distinguish  the  psychic  side  of  the 
gradually  developed  dementia  of  epileptics.  The  mental  enfeeblement 
is  accompanied,  as  in  terminal  dementias  generally,  by  increase  in 
bodily  weight,  hypertrophy  of  the  subcutaneous  fatty  tissue,  and  the 
gradual  effacement  of  the  lines  of  expression  in  the  features.  We  thus 
reach  ultimately  the  condition  of 

Epileptic  Dementia. — As  intimated,  the  rate  of  progress  of 
epileptic  dementia  is  in  direct  proportion  to  the  number  and  severity  of 
seizures.  There  are  cases  which  go  on  to  the  terminal  stage  without 
some  of  the  peculiar  manifestations  of  progressive  epileptic  degeneration 
just  described,  and  others,  again,  in  which  these  features  are  prominent. 
The  dementia  may  be  absolute,  so  that  not  the  simplest  concrete  memory- 
picture  remains  in  the  vacant  mind  ;  the  patient  needs  care  in  his  ])er- 
son  and  dress,  and  often  has  to  be  guided  and  assisted  in  taking  nourish- 
ment. His  sensibilities  become  so  diminished  that  he  is  indifferent  to 
stimulation  of  any  sense,  and  has  no  perception  of  the  needs  of  the  body 
as  regards  the  bowels  or  bladder.  He  must  be  cared  for  like  an  infant. 
A  persistent  sexual  instinct  often  impels  him  to  constant  masturbation. 

During  progress  into  dementia,  we  note  the  intercurrent  hallucinatory 
states  already  mentioned,  and  the  accesses  of  anger,  with  assaults  and 
impulsive  actions  of  various  kinds.  The  motor  memories  suffer  in  the 
end  to  such  degree  that  all  complicated  movements  are  forgotten.  This 
is  particularly  noteworthy  in  the  use  of  words,  which  are  separated  by 
considerable  pauses.    Often  even  the  syllables  are  thus  divided.    Finally,. 


EPILEPTIC  INSANITY.  797 

the  patient  loses  the  power  of  speech  altogether  (aside  from  the  actual 
aphasic  attacks,  which  are  not  infrequently  observed  in  connection  with 
severe  epileptic  seizures). 

The  course  of  epileptic  dementia  is  rarely  rapid  ;  it  usually  extends 
over  a  period  of  years.  The  cause  of  death  is  usually  accident,  status 
epilepticus,  pneumonia,  intestinal  catarrh,  inflammation  of  the  bladder, 
or  some  other  intercurrent  affection.  Epileptic  dements  exhibit  a 
diminished  resistance  to  diseases  in  general,  and  never  attain  great  age. 

Acute  Transitory  Epileptic  Insanity. — The  acute  insanity  of 
epileptics  develops  suddenly  before  a  convulsive  seizure,  after  the  attack, 
or  it  may  occur  in  the  interval  between  the  epileptic  convulsions,  com- 
monly in  the  })lace  of  a  convulsion,  as  a  so-called  psychic  equivalent. 
As  a  rule,  both  onset  and  termination  are  sudden.  The  duration  of  the 
insanity  is  ordinarily  from  a  few  hours  to  a  few  days,  though  the  attacks 
are  sometimes  shorter  and  sometimes  longer.  The  symptoms  are  pecu- 
liar and  various.  The  chief  characteristic  is  the  clouding  of  conscious- 
ness. The  patient's  state  may  be  one  of  complete  unconsciousness, 
though  usually  consciousness  is  not  entirely  lost.  It  is  rather  a  condi- 
tion of  subconsciousness  or  of  subliminal  consciousness,  with  stupor. 
Upon  this  screen  of  clouded  consciousness  there  is  a  play  of  multiform 
and  bizarre  psycopathic  outlines — many-hued,  terrible,  or  ecstatic  hallu- 
cinations ;  delirium,  mutism,  incoherence,  verbigeration,  anxious  states, 
delusions  (often  of  a  persecutory  nature),  or  irresistible  impulsions  to 
assault,  destructiveness,  homicide,  and  suicide.  Sometimes  the  funda- 
mental tone  of  the  outbreak  is  melancholic,  more  often  maniacal,  but 
the  most  appropriate  designation  of  these  acute  epileptic  psychoses  is, 
perhaps,  acute  hallucinatory  paranoia.  There  is  no  essential  difference 
between  them,  whether  the  attack  be  preparoxysmal  or  postparoxysmal, 
or  the  equivalent  of  the  paroxysm. 

The  stupor  of  epileptic  insanity  is  distinguished  from  that  of  other 
psychoses  by  marked  loss  of  consciousness,  enfeebled  attention,  anal- 
gesia, sudden  violence,  and  confusion. 

We  sometimes  observe  in  connection  with  subconsciousness  primary 
anxious  states,  resembling  precordial  dread,  with  extremely  painful 
sensations  of  oppression  and  suffocation  in  the  breast ;  and  much  more 
rarely  primordial  exaltation,  with  acceleration  of  the  stream  of  ideas. 

Hallucinations  are  mostly  limited  to  the  visual,  auditory,  and  olfac- 
tory senses,  chiefly  to  the  first-named.  The  patient  sees  wild  beasts, 
specters,  flames,  the  fires  of  hell,  wheels,  gigantic  threatening  objects, 
falling  walls,  overwhelming  waves  of  water ;  or,  on  the  other  hand,  the 
golden  gates  of  heaven,  the  jasper  throne,  God,  and  the  choir  of  angels. 
He  hears  menaciilg  voices,  clamor  and  uproar,  the  thunder  of  cannon, 
or  the  singing  of  the  hosts  of  heaven,  the  voice  of  God,  etc.  Disagree- 
aible  and  noxious  or  pleasant  odors  may  be  perceived.  A  peculiarity 
of  these  hallucinations  is  a  certain  monotony  of  character,  a  general 
sameness,  in  great  part  due  to  the  rather  child-like  constitution  of  the 
mind  of  epileptics.  Their  education  and  mental  evolution  are  so  often, 
from  the  nature  of  their  malady,  hampered  and  retarded,  that  they  pass 
through  life  with  the  fancy  and  understanding  of  a  child. 


798  MENTAL  DISEASES. 

Incoherence  of  speech  and  lack  of  orientation  as  to  surroundings 
are  more  marked  in  epileptic  insanity  than  in  any  other  psychosis. 

The  motor  symptoms  vary  extremely.  Sometimes  we  note  motor 
inhibition  attaining  to  complete  immobility  and  mutism,  lasting  for 
hours,  days,  or  weeks  at  a  time.  Such  quiescence  is  often  interrupted 
by  sudden  explosive  acts  of  violence.  Again,  in  other  cases,  we  ob- 
serve agitation,  restless  wandering  about,  purposeless  and  impetuous 
running  hither  and  thither,  assaults,  destructiveness,  and,  rarely,  com- 
plicated acts,  like  theft  and  other  petty  crimes.  A  condition  of  relig- 
ious ecstasy  is  not  uncommon.  The  patient  may  feel  himself  wafted  to 
heaven,  where  he  converses  with  God,  Christ,  and  the  disciples. 

In  some  rare  instances  epileptics  are  subject  to  dream-like  states  of 
subconsciousness,  similar  to  somnambulism,  in  which  complicated  acts 
are  carried  out.  Like  the  somnambulist,  such  patients  may  seem  to  be 
conscious,  may  comport  themselves  in  speech  and  conduct  in  a  perfectly 
natural  manner,  and  in  this  condition,  which  may  last  for  hours,  days, 
or  even  weeks,  commit  offenses  against  the  law,  wander  off  as  tramps, 
or  do  some  extraordinary  thing  in  following  the  imperative,  childish, 
silly,  or  fantastic  ideas  which  control  their  dream-state. 

The  disorders  of  memory  incident  to  transitory  epileptic  insanity 
are  both  interesting  and  important.  There  may  be,  upon  recovery,  ab- 
solute amnesia  as  regards  everything  that  has  taken  place.  There  may 
be  remembrance  of  much  that  has  occurred  immediately  after  the  in- 
sanity has  passed,  with  subsequent  amnesia.  There  may  be  complete 
amnesia  at  first,  with  glimpses  of  remembrance  afterward.  There  is 
rarely  any  persistent  recollection  of  the  events  of  the  psycopathic 
state. 

As  has  been  stated,  the  rule  is  for  these  transitory  epileptic  insanities 
to  exhibit  a  sudden  onset  and  a  sudden  termination.  The  longer  the 
duration,  the  less  abrupt  the  cessation.  The  majority  of  these  patients 
recover,  but  recurrence  is,  of  course,  frequent.  Termination  in  a  chronic 
condition  is  rare.  Occasionally,  death  takes  place  from  exhaustion,  in- 
tercurrent maladies,  or  from  a  convulsive  seizure  or  series  of  attacks 
during  the  psychosis.  Recurrences  tend  to  hasten  a  psychic  degenera- 
tion ending  in  dementia. 

The  epileptic  nature  of  such  insanity  as  is  here  described,  where  the 
history  is  not  known,  is  determined  by  the  following  characteristics  :  (1) 
Sudden  onset  and  abrupt  termination ;  (2)  the  terrifying  or  ecstatic 
nature  of  the  hallucinations  and  delusions  ;  (3)  disturbance  of  conscious- 
ness and  stuporous  condition  ;  (4)  impulsive  acts  ;  (5)  dream-states  ;  (6) 
amnesia. 

Chronic  Epileptic  Insanity. — Aside  from  epileptic  dementia,  the 
acute  epileptic  psychosis  just  described  may  take  a  chronic  course,  or 
assume  a  periodic  form,  with  little  improvement  in  the  intervals  between 
the  exacerbations.  There  are  cases  which  closely  resemble  chronic 
mania  in  their  long  course,  and  others  in  which  melancholia  is  the  pre- 
dominating feature.  The  epileptic  attacks  to  which  these  patients  are 
subject  are  naturally  the  distinguishing  feature,  and  a  special  color  is 
given  such  cases  by  the  epileptic  psychic  degeneration.     Occasionally  a 


EPILEPTIC  INSANITY.  799 

true   circular    insanity  is  presented,  with  its  alternating  maniacal  and 
melancholic  phases. 

Treatment. — Most  cases  of  pronounced  epileptic  insanity  require 
commitment  to  an  asylum.  Their  proclivity  to  sudden  accesses  of  rage 
and  fury  and  to  impulsive  acts  of  violence  necessitates  this  course. 
Where  there  is  simply  a  moderate  amount  of  psychic  degeneration  this 
course  is  not  necessary. 

The  treatment  should  be,  in  the  first  instance,  prophylactic  ;  but,  after 
the  development  of  the  psychosis,  it  consists  of  a  combination  of  the 
treatment  of  ordinary  epilepsy  with  that  of  the  particular  type  of  insanity 
presented. 

Preventive  therapy  is  concerned  with  the  counteraction  of  the  many 
elements  which  favor  mental  deterioration,  with  the  mitigation  of  the 
epileptic's  early  sufferings,  with  the  reconstruction  of  his  environment. 
It  may  be  called  the  moral  and  manual  method.  The  moral  part  of  it 
is  the  opportunity  for  education,  regular  occupation,  and  recreation. 
The  manual  and  hygienic  part  of  it,  the  acquisition  of  out-of-door  trades 
or  callings — muscular  exercise,  which  in  itself  serves  to  reduce  the 
number  and  intensity  of  convulsive  seizures.  I  may  be  pardoned  for 
dwelling  somewhat  longer  on  this  subject  of  preventive  therapy,  and  for 
allowing  my  pen  to  go  over  the  same  lines  which  it  has  traveled  so 
often  in  past  years,  because  I  am  convinced  that  this  moral  treatment 
marks  the  greatest  stride  in  advance  made  for  centuries  in  the  thera- 
peutics of  epilepsy.  For  ages  drugs  have  been  exploited  as  helpful  or 
curative  ;  but,  after  all,  little  has  been  accomplished  from  the  standpoint 
of  materia  medica.  Only  of  late  years  has  the  moral  treatment  become 
prominent.  As  a  rule,  the  epileptic  patient  was  dismissed  by  his  physician 
with  a  prescription  of  uncertain  value  and  possibly  a  few  general  direc- 
tions as  to  diet.  It  was  not  known  to  the  practitioner — or,  at  least,  he 
did  not  concern  himself  about  the  matter — that  the  epileptic  could  gain 
admission  to  no  hospital  of  any  kind  ;  that  he  had  no  associates,  occu- 
pation, or  recreation  ;  that,  debarred  from  the  schools,  he  grew  up  un- 
educated, and  with  a  tendency  toward  retrogression  rather  than  progress  ; 
and  that,  without  teaching,  reared  in  idleness,  suffering  from  a  dreadful 
malady,  neglected  in  body  and  mind,  he  could  find  shelter  at  last  only 
in  the  almshouses  and  insane  asylums,  these  being  the  only  institutions 
open  to  him.  Yet,  in  by  far  the  majority  of  cases  of  epilepsy,  the 
attacks  rob  them  for  but  brief  intervals  of  the  capacities  for  study, 
work,  recreation,  and  social  pastimes,  which  they  possess  in  common 
with  their  more  fortunate  fellow-men.  Hence  the  adoption  of  a  scheme 
of  colonization  of  epileptic  dependents  on  the  model  of  the  great  German 
colony  at  Bielefeld,  of  which  the  Craig  Colony,  in  the  State  of  New 
York,  is  an  example.  The  Craig  Colony  consists  of  a  tract  of  nearly 
nineteen  hundred  acres  of  land  in  the  most  fertile,  productive,  and  pictur- 
esque valley  of  the  State  (the  Genesee  Valley).  Upon  this  are  already 
some  sixty  to  eighty  buildings,  with  accommodations  at  present  for  but 
840  patients.  Over  eleven  hundred  epileptics  are  now  on  the  list  of 
patients  awaiting  admission.  Here  they  are  to  be  given  an  education 
in  the  various  branches  of  learning  taught  in  the  public  schools,  to  be 


800  3IEXTAL   DISEASES. 

instructed  in  every  kind  of  industr^^,  to  be  treated  each  and  every  one 
for  epilepsy,  and  to  be  oifered  a  home  in  a  sort  of  village  life,  where 
they  will  no  longer  have  the  feeling  of  social  ostracism,  or  be  debarred 
from  the  privileges  of  intellectual  and  moral  development  enjoyed  bv 
the  rest  of  mankind. 

The  out-of-door  life  in  a  farming  community  has  already  had 
wonderful  results,  which  may  be  learned  from  the  annual  reports  of 
the  colony.  It  will  suffice  to  say  here  that  the  average  reduction  in 
frequency  of  attacks  among  all  the  patients  has  been  fully  fifty  per 
cent.,  and  that  the  mental  and  moral  regeneration  of  the  beneficiaries 
has  been  truly  remarkable.  What  the  effect  of  such  change  of  environ- 
ment must  be  as  a  prophylactic  against  psychic  degeneration  and  insanity 
can  not  be  estimated.  We  may  now  briefly  touch  upon  the  medicinal 
and  surgical  treatment  of  epilepsy.  The  old  drugs — ^l^orax,  nitrate  of 
silver,  belladonna,  and  the  bromids — have  their  uses.  One  is  valuable 
in  one  case  and  not  in  the  other ;  and  each  patient,  where  the  disease  is 
idiopathic,  and  no  etiological  indication  exists  for  the  preferment  of  an 
especial  agent,  must  be  experimented  upon  with  one  drug  after  another 
for  two  or  three  months  at  a  time,  until  a  satisfactory  remedy  is  discov- 
ered. Upon  the  whole,  the  bromids  are  most  effective  as  a  general 
antispasmodic  for  all  cases.  While  the  bromids  are,  perhaps,  the  most 
useful  remedy  we  can  employ  as  an  antispasmodic  in  many  cases  of 
epilepsy,  their  exhibition  in  every  case  is  not  advisable.  With  a  con- 
siderable number  of  patients  the  bromids  are  entirely  ineffectual ;  ^yith 
no  small  number,  too,  very  serious  symptoms,  such  as  acute  bromism, 
increase  of  seizures,  and  even  insanity,  supervene  upon  their  use.  In 
many  of  the  cases  where  actual  good  is  done  by  the  bromids  in  reduc- 
ing the  frequency  and  severity  of  the  attacks,  the  concomitant  symptoms 
are  such  that  it  becomes  questionable  whether  the  remedy  be  not,  after 
all,  worse  than  the  disease.  The  writer  makes  it  a  practice,  therefore,  to 
exhibit  the  bromids  with  caution,  and  never  to  employ  them  until  the 
series  of  less  harmful,  but  often  quite  as  efficacious,  remedies  for  epilepsy 
have  been  tried  in  vain. 

There  are  some  new  drugs  and  remedial  methods  that  have  come 
into  vogue  of  late  which  are  worthy  of  attention.  In  the  first  place, 
there  is  simulo,  a  South  American  plant  of  the  hyssop  family,  the  tinc- 
ture of  which  is  given  in  doses  of  one  to  two  or  three  drams  three  times 
daily.  After  an  experience  in  many  cases  for  several  years,  I  would 
say  of  simulo  that  it  deserves  trial  in  most  cases ;  that  it  is  perfectly 
harmless,  which  can  not  be  said  of  the  bromids,  borax,  belladonna,  and 
some  other  drugs ;  that  in  a  few  cases  it  has  been  extremely  beneficial 
in  my  hands,  and  that  in  most  cases  it  has  no  effect  at  all.  Simulo 
combined  with  small  doses  of  bromid  acts  very  well.  The  so-called 
opium-bromid  treatment  of  Flechsig  is  of  value  for  many  patients, 
especially  in  old  and  obstinate  cases  where  all  other  agents  have  proved 
ineffectual.  This  treatment  consists  of  the  administration  of  opium  for 
some  six  weeks,  beginning  with  one-half  to  one  grain  three  times  daily, 
and  increasing  gradually  until  ten  to  fifteen  grains  a  day  are  taken,  when 
the  use  of  opium  is  suddenly  stopped,  and  bromids  in  large  and  grad- 


EPILEPTIC  INSANITY.  801 

ually  reduced  doses  are  given  (thirty  grains  four  times  daily,  to  Ijegin 
witbj.  I  had  used  in  certain  cases  of  epileps}-  for  some  years  codein 
with  consid(!rable  success,  Init  this  combination  of  the  opiate  with  bro- 
mids  is  still  more  satisfactory. 

Adonis  vernalis  conjoined  with  the  bromids,  as  recently  suggested 
by  Bechterew,  is  an  efficient  method  of  treatment,  from  which,  in  several 
instances,  I  have  had  gratifying  results.  Digitalis,  which  has  proper- 
ties similar  to  Adonis  vernalis,  was  formerly  frequently  given  in 
epile[)sy,  but  the  new  combination  seems  to  l)e  much  more  efficaci(jus. 

There  are  a  few  cases  of  epilepsy  in  wliich  careful  investigation  indi- 
cates self-intoxication  as  a  factor.  In  these  an  excess  of  ethereal  sul- 
phates (indican)  in  the  urine,  together  with  periodical  or  constant  attacks 
of  gaseous  diarrhea,  are  almost  positive  manifestations  of  putrefactive 
or  fermentative  changes  taking  place  in  the  alimentary  tract.  It  is  re- 
markable how  much  benefit  may  l)e  obtained  in  such  patients  by  the 
regulation  of  the  diet  (milk  and  its  mddifications,  koumiss,  matzoon, 
somal,  rare  or  raw  beef,  eggs,  green  vegetables,  and  special  breadstuffs, 
like  Zweiback,  Huntley  &  Palmer's  breakfast  biscuits,  and  Voebt's 
biscotfe  de  legumine^,  by  the  frequent  drinking  of  hot  water  and  the 
occasional  flushing  out  of  the  large  intestine  by  hot  water,  and  by  the 
use  of  certain  intestinal  antiseptics,  given  two  hours  after  eating,  with 
plenty  of  water  (beta-naphtol  or  salol,  gr.  v). 

The  remarkable  effect  of  the  thyroid  extract  upon  general  nutrition 
would  naturally  suggest  the  advisability  of  its  administration  for  experi- 
mental purposes  in  some  of  the  nervous  diseases  which  we  are  accus- 
tomed to  look  upon  as  due  to  nutritional  disturbances  in  the  nervous 
system.  With  this  idea  in  view,  I  have  employed  it  in  a  good  many 
cases  of  epilepsy,  in  a  number  with  very  good  effect.  Especially  note- 
worthy was  mental  improvement  in  several  cases  of  epilepsy  with 
apparently  considerable  dementia.     It  is  worthy  of  more  extended  trial. 

Aside  from  the  remedies  for  the  epilepsy  just  described,  we  need 
occasionally  to  employ  certain  other  drugs  for  particular  conditions, 
such  as  status  epilepticus,  maniacal  outl)reaks,  pronounced  melan- 
cholic states  of  terror,  etc.  In  status  epilepticus  rectal  injections  of 
chloral,  gr.  xx,  with  an  ounce  of  starch-water,  repeated  at  intervals  of 
two  or  three  hours  if  needed,  give  the  most  satisfaction.  In  great  ideo- 
motor  excitement  we  should  use  hyoscin,  hyoscyamin,  or  duboisin 
hypodermatically,  in  doses  of  yito  ^^  tV  '^^  ^  grain.  In  anxious  melan- 
cholic conditions  morphin  hypodermatically  is,  perhaps,  the  best  allevi- 
ating agent  to  exhibit. 

The  question  of  trephining  must  naturally  come  up  in  certain  cases 
of  epileptic  psychoses  where  trauma  to  the  head  is  evidently  the  cause 
of  the  epilepsy  and  psychic  degeneration.  The  following  points  are  to 
be  taken  into  consideration  as  a  guide  in  this  matter : 

1.  In  the  very  small  number  of  cases  having  injury  to  the  head  as 
a  cause  the  epileptic  habit  is  so  strong,  and  the  changes  in  the  l>rain 
are  usually  so  old  and  deep-seated,  that  an  operation,  as  a  rule,  does 
not  cure,  and  seldom  permanently  diminishes  the  frequency  of  the 
attacks. 
51 


802  3IENTAL  DISEASES. 

2.  Of  miscellaneous  traumatic  cases,  where  a  surgical  procedure 
seems  justifiable  and  is  undertaken,  a  cure  of  the  epilepsy  may  be 
reasonably  expected  in,  perhaps,  four  out  of  every  hundred  cases 
operated  upon. 

3.  The  removal  of  a  cicatrix  from  the  cortex,  supposed  to  be  the 
epileptogenic  nidus,  will  naturally  be  followed  by  the  formation  of  a 
new  cicatrix  in  the  surgical  wound — the  creation,  therefore,  of  a  new 
epileptogenic  center. 

4.  The  more  recent  the  injury,  the  greater  will  be  the  promise  of 
lasting  benefit. 

5.  In  cases  of  traumatic  epilepsy  with  marked  epileptic  psychoses 
(recurrent  attacks  of  rage,  fury,  violence,  destructiveness,  etc.)  trephin- 
ing would  be  justifiable  as  a  possible  means  of  diminishing  the  severity, 
danger,  and  frequency  of  the  maniacal  attacks,  even  though  the  epilepsy 
itself  or  the  psychic  degeneration  might  not  be  improved. 


CHAPTER    X. 

DEMENTIA. 

Secondary;  Senile;  Primary* 

Definition. — "  Dementia  "  is  a  term  employed  to  designate  simply  a 
general  enfeeblement  of  all  the  mental  faculties.  It  is  often  used  im- 
properly by  the  laity  as  synonymous  with  insanity.  But  in  medicine  it 
signifies  only  a  general  weakening  of  a  mind  once  normal.  Hence  it  is 
not  applied  to  congenital  mental  weakness.  The  term  '^  idiocy,"  with  its 
various  degrees,  includes  all  of  these  congenital  psychic  defects.  There 
are  innumerable  gradations  comprised  in  dementia,  from  the  merest 
dullness  to  profound  deficiency  or  complete  loss  of  all  the  intellectual 
faculties.  Such  enfeeblement  of  the  mind  may  be  the  result  of  serious 
cerebral  diseases  or  disorders,  such  as  epilepsy,  alcoholism,  syphilis,  etc., 
vi^hen  the  dementia  is  qualified  as  epileptic,  alcoholic,  syphilitic  dementia, 
etc.  It  is  often  a  sequel  to  acute  insanities,  like  mania  and  melancholia, 
and  to  chronic  psychoses,  like  circular  insanity  and  paranoia,  and  hence 
the  distinctive  term  secondary  dementia  applied  to  such  examples.  It 
takes  the  chief  part  in  the  syndrome  of  paresis,  so  that  that  disorder  is 
often  entitled  "  paralytic  dementia."  Progressive  mental  enfeeblement 
not  infrequently  accompanies  senile  involution  and  organic  changes  in 
the  brain  incident  to  that  epoch  of  life  ;  hence  the  well-known  disorder 
called  senile  dementia.  Finally,  there  is  a  form  of  mental  disease  charac- 
terized in  the  main  from  the  very  beginning  by  extraordinary  psychic 
enfeeblement,  and  this  malady  is  classified  as  an  acute  or  primajy 
dementia. 


DEMENTIA.  803 


Under  the  heading  of  dementia  we  shall  now  consider  separately  the 
more  important  forms  of  dementia  just  described — viz.,  secondary 
dementia,  senile  dementia,  and  primary  dementia. 


SECONDARY  DEMENTIA. 

Secondary  dements  make  up  by  far  the  greater  number  of  the 
patients  accumulated  in  our  large  asylums.  Every  year  the  number  is 
augmented  by  the  increment  of  new  cases  which  enter  upon  this  terminal 
and  incurable  condition.  It  has  been  estimated  that  some  two-thirds  of 
the  patients  in  asylums  belong  to  this  category. 

Symptomatology. — The  cardinal  symptoms  are  defect  of  memory, 
deficient  ideation,  and  feebleness  of  judgment.  There  is  no  longer  any 
logical  co5rdination  in  the  flow  of  thought.  The  speech  is  incoherent 
when  there  are  any  ideas  at  all  to  seek  expression.  Some  patients 
chatter  a  great  deal  with  no  coherence  or  meaning,  the  only  connection 
of  one  word  or  phrase  with  another  being  similarity  of  sound.  Other 
patients  are  absolutely  silent.  Hallucinations  are  often  present,  more 
particularly  at  the  period  of  transition  from  the  antecedent  psychosis  to 
the  terminal  dementia.  Delusions  may  also  exist,  but  they  are  vestiges 
of  the  delusions  of  the  primary  insanity  carried  over  into  the  secondary 
condition.  The  feebleness  of  mind  is  shown  especially  in  the  state  of 
the  emotions,  which  have  a  child-like  simplicity  of  expression.  These 
patients  laugh  boisterously  over  nothing,  weep  about  trifles,  and  are 
easily  enraged  without  sufficient  motive.  Naturally,  all  of  the  higher 
concepts  are  lost,  especially  those  of  esthetic  and  ethical  character. 
The  habits  become  depraved  and  loathsome  in  extreme  cases.  Mastur- 
bation, destructiveness  of  clothing,  besmearing  of  the  person  with  and 
eating  of  filth  are  frequent  manifestations  in  the  lowest  degrees  of 
dementia.  The  patients  become  robust  and  fat.  They  lose  all  expression, 
save  some  single,  automatic,  fatuous  smile,  angry  frown,  furtive  look,  or 
aspect  of  misery,  which  may  linger  as  a  legacy  from  the  previous  psy- 
chosis. They  swallow  anything  they  can  get  hold  of;  they  collect 
pebbles,  pieces  of  paper,  string,  glass, — in  fact,  all  sorts  of  rubbish, — 
which  they  either  pocket  or  use  for  personal  ornament.  Many  show  a 
proclivity  to  automatic  movements,  analogous  to  those  observed  in 
idiocy,  such  as  anteroposterior  or  lateral  oscillations  of  the  body.  Occa- 
sionally these  movements  are  more  complicated,  taking  the  form  of 
grimaces  ;  gesticulations  with  the  fingers,  hands,  and  arms  ;  running  to 
and  fro,  running  in  a  circle,  whirling  round  on  the  heel,  etc.  A  con- 
siderable loss  of- sensibility  to  pain  is  generally  noticeable  in  secondary 
dements.     Hematoma  auris  is  common  among  them. 

It  is  customary  to  classify  secondary  dementia  into  two  groups,  be- 
speaking contrasting  syndromes — viz.,  apathetic  and  agitated  dementia. 

Patients  with  apathetic  dementia  are  expressionless,  never  speak, 
crouch  or  lie  about  the  floor  or  in  corners  in  the  most  negligent  attitudes, 
and  cover  their  heads  with  their  clothing. 

Patients  with  agitated  dementia  are  the  restless  ones  just  alluded  to, 


804  MENTAL   DISEASES. 

and  such  cases  as  show  a  tendency  to  accesses  of  excitement.  These 
outbreaks  are  doubtless  aroused  by  processes  going  on  within  the  organ- 
ism, since  they  occur  without  any  external  exciting  cause. 

Secondary  dementia  may  be  regarded  as  a  presentment  of  the  mind 
in  ruins.  Tlie  storm  has  swept  by  with  its  havoc  and  devastation. 
After  its  fury  has  been  spent,  a  certain  amount  of  placidity  remains. 
In  the  midst  of  this  calm  we  note  the  wreck  that  has  been  wrought. 
Some  of  the  old  architectural  details  stand  out,  so  that  we  may  still  rec- 
ognize what  manner  of  mind  it  was.  There  are  residua,  too,  of  the 
destructive  agent  that  was  at  work,  traces  that  indicate  the  charactei' 
of  the  brain-storm  when  it  was  at  its  height. 

The  foregoing  are  the  main  outlines  of  secondary  dementia,  but,  as 
intimated  before,  there  are  innumerable  gradations  of  mental  enfeeblement 
in  these  cases.  A  large  part  of  the  work  done  in  and  about  asylums  is 
performed  by  secondary  dements  in  whom  the  intellectual  decay  is  not 
extreme. 

Course  and  Prognosis. — The  course  of  secondary  dementia  is 
chronic.  Usually,  there  is  no  progressive  increase  of  mental  enfeeble- 
ment, rather  a  pause  after  a  time,  when  the  mind  reaches  a  certain 
plane  of  deterioration.  Here  the  process  becomes  stationary.  The 
patient  leads  his  mindless,  vegetative  existence  for  years  and  years, 
sometimes  to  a  good  old  age,  because  in  the  asylum  he  lives  a  life  of 
perfect  regularity  as  to  food,  sleep,  and  exercise,  and  is  snugly  pro- 
tected from  the  vicissitudes  of  weather  and  of  the  daily  struggle  in  the 
outer  world. 

These  patients  never  recover.  Actual  tissue-alterations  were  made 
by  the  psychosis  which  swept  through  their  brains. 

Pathological  Anatomy. — Thickening  of  the  vascular  walls,  dis- 
tention of  the  perivascular  spaces,  destruction  of  ganglion-cells  and 
cortical  association  fibers,  and  some  narrowing  of  the  cortex — these  are 
the  main  postmortem  findings. 


SENILE  DEMENTIA. 

,  This  is  a  progressive  mental  enfeeblement  at  the  period  of  senile 
involution,  dependent  upon  organic  changes  in  the  brain  :  therefore,  a 
chronic  organic  psychosis. 

Etiology. — Heredity  has  been  noted  in  some  fifty  per  cent,  of  the 
cases.  Males  and  females  suifer  about  equally.  The  disorder  rarely 
appears  before  the  sixtieth  year.  Mental  stress  and  physical  illness, 
together  with  the  senile  involution,  are  the  chief  etiological  factors.  In 
most  of  the  cases  arteriosclerosis  takes  part  in  the  causation  of  the 
disease,  inducing,  as  it  does,  general  malnutrition  of  the  brain,  as  well 
as  frequent  local  degenerations  of  small  or  large  extent. 

Symptomatology. — The  earliest  symptom  is  failure  of  memory. 
The  most  recent  memories  disappear  first  in  a  sort  of  chronological 
order.  After  a  time  the  patient  fails  to  recognize  any  of  his  surround- 
ings or  any  of  the  people  about  him.     He  converses  with  those  near 


DEMENTIA.  805 

him,  and  miscalls  them,  as  if  they  were  old  friends  of  long  years  ago. 
He  lives  over  old  events  as  if  tiiey  were  now  enacted.  Later  on  even 
these  old  memories  vanish  also.  With  failing  memory,  the  judgment- 
associations  perish.  The  patient  commits  many  breaches  of  decorum, 
and  later,  with  the  degeneration  of  ethical  feelings  and  the  ascendancy 
of  coarser  instincts,  may  become  very  negligent,  indecent,  and  unclean 
in  habits ;  may  pilfer  and  destroy  things ;  may  expose  his  person,  mas- 
turbate, or  attempt  liberties  with  little  girls,  etc.  His  loss  of  judgment 
may  induce  him  to  foolishly  squander  his  money  and  properties. 

Illusions  and  hallucinations  begin  to  manifest  themselves.  They  are 
usually  of  terrifying  character. 

Delusions  make  their  appearance.  These  are  nearly  always  perse- 
cutory in  nature,  and  arise  either  as  primary  ideas  or  as  the  result  of 
depression  or  on  the  basis  of  hallucinations.  Next  to  delusions  of 
persecution  in  frequency,  we  observe  hypochondriacal  delusions,  with 
contents  modified  by  the  weak-mindedness  present.  Delusions  of  ap- 
proaching poverty  are  quite  common. 

The  underlying  mood  is  often  melancholic  ;  an  exalted  mood  is  ex- 
tremely rare.  Changeability  with  irritability  is  perhaps  the  most  usual 
affective  condition. 

The  behavior  of  these  patients  in  relation  to  night  is  noteworthy. 
Illusions,  hallucinations,  delusions,  and  emotional  states  all  become 
more  pronounced  at  night.  A  striking  feature,  too,  is  extreme  motor 
restlessness,  especially  at  night.  These  patients  try  to  get  up  from 
bed,  to  wander  about  the  house,  to  get  away  from  something  or  some- 
body. Sometimes  true  melancholic  anxious  states  come  on  and  lead  to 
attempts  at  suicide. 

So  far  as  bodily  symptoms  are  concerned,  we  note  foremost  among 
them  a  general  senile  decrepitude,  to  which  are  added  senile  tremor  of 
the  hands,  and  often  various  stigmata  of  focal  lesions  in  the  brain 
(aphasic  and  paraphasic  attacks) ;  sometimes  hemiparesis,  monoplegia, 
hemiplegia,  etc.,  complicate  the  picture.  The  patients  often  complain 
of  severe  pains  all  over  the  body,  of  vertigo,  ringing  in  the  ears,  sparks 
before  the  eyes,  etc.  Often,  too,  there  is  noticeable  diminution  of  sen- 
sibility to  touch  and  pain  in  various  areas,  or  over  the  whole  body. 
Occasionally  an  especial  color  is  given  to  the  symptoms  described  by 
true  maniacal  or  melancholic  phases  appearing  in  the  course  of  the  dis- 
ease. 

Course  and  Prognosis. — Senile  dementia  develops  gradually  upon 
the  basis  of  senile  psychic  degeneration,  and  lasts,  ordinarily,  from 
three  to  five  years,  sometimes  with  remissions  which  are  never  so  note- 
worthy as  the  remissions  of  paralytic  dementia.  In  rare  instances 
an  acute  course  is  taken,  the  disease  terminating  by  death  in  a  few 
months.  Paralytic  attacks  are  not  infrequently  observed  in  the  course 
of  the  malady,  giving  it  a  certain  analogy  to  paresis.  The  prognosis  is 
unfavorable,  as  the  disorder  is  incurable  and  progressive  to  a  fatal  end. 

Diagnosis. — The  most  important  indications  for  diagnosis  are 
defects  of  memory  and  judgment  and  acts  dependent  upon  loss  of 
ethical  feeling. 


806  MENTAL   DISEASES.  ' 

Pathological    Anatomy. — We    observe    at   autopsy    chiefly   tlie 
following  conditions  ; 

1.  Osteophytic  deposits  on  the  inner  surface  of  the  skull. 

2.  Pachymeningitis  hsemorrhagica  interna    (more    frequently    even 
than  in  paralytic  dementia). 

3.  Opaque  and  thickened  leptomeninges. 

4.  Increased  fluid,  subdural,  and  in  the  meshes  of  the  pia-arachnoid. 

5.  Distention  of  the  ventricles  with  serum,  and  granular  ependyma. 

6.  Extreme  narrowing  of  the  cortex,  with  gaping  sulci. 

7.  General  endarteritis  deformans  (often  with  foci  of  softening  and 
hemorrhage). 

8.  Wide-spread  degeneration  of  ganglion-cells  and  association  fibers. 
Treatment. — Many  cases  of  senile  dementia  can  be  treated  at  home. 

It  is  only  when  tendencies  to  suicide,  sexual  immoralities,  waste  of 
property,  and  great  ideomotor  excitement  are  exhibited  that  commitment 
is  necessary.  The  bromids  are  the  best  hypnotic  for  these  cases. 
Paraldehyd  is  extremely  useful,  too,  since  it  is  efficient  as  a  hypnotic 
and  does  not  injure  the  circulation  or  affect  the  digestive  apparatus.  In 
melancholic  phases  opium  acts  well.  Hyoscin  and  its  congeners  are 
not  to  be  recommended  because  of  their  depressing  action  on  the  heart. 


PRIMARY  DEMENTIA. 

Synonyms. — Acute  dementia  ;  Acute  curable  dementia  ;  Stupiditas. 

Definition. — Primary  dementia  is  an  acute  curable  psychosis  charac- 
terized by  ideomotor  inhibition  and  apathy.  The  inhibition  of  thought 
may  attain  to  the  degree  of  complete  cessation  of  the  psychic  functions, 
and  that  of  motion  to  complete  immobility. 

Etiology. — This  is  essentially  a  disorder  of  youth.  A  rare  disease 
in  itself,  it  is  chiefly  encountered  in  young  persons  between  the  ages  of 
puberty  and  thirty  years.  After  thirty-five  it  is  extremely  infrequent. 
A  neuropathic  constitution  is  found  in  some  sixty  per  cent,  of  the  cases. 
Any  mental  or  physical  stress  that  induces  exhaustion  of  the  nervous 
system  may  act  as  an  exciting  cause  of  primary  dementia.  Fright,  con- 
cussion of  the  brain  from  trauma,  hemorrhages,  frequent  child-bearing, 
physical  and  mental  overwork  or  overexertion,  and  masturbation  have 
all  been  cited  as  etiological  factors. 

Symptomatology. — The  development  of  the  malady  is  gradual. 
At  first  there  is  difficult  concentration  of  the  thoughts  with  loss  of  in- 
terest in  everything  and  a  certain  restlessness.  The  patient  perceives  a 
lack  of  energy  in  his  idea-associations  ;  nothing  suggests  thoughts  to  him, 
and  he  begins  to  feel  a  sort  of  depressed  wonder  at  his  own  condition. 
Complicated  processes  of  thought  become  impossible,  and  even  the 
simplest  concrete  memory-pictures  are  difficult  of  recollection.  He  can 
not  recall  the  countenances  of  his  friends,  the  position  of  the  furniture  in 
his  room,  the  situation  of  his  home,  the  events  of  the  past  or  of  yesterday. 
He  feels  his  head  empty  of  ideas.  Things  seem  to  grow  distant ;  voices 
sound  far  away.     The  senses  become  blunted  and  respond  at  first  slowly, 


DEMENTIA.  807 

later  not  at  all,  to  stimuli.  The  patient  sinks  deeper  and  deeper  into 
u  dream-state.  His  face  becomes  expressionless,  his  eyes  staring  into 
vacancy.  He  makes  no  response  to  questions.  He  pays  no  attention  to  his 
surroundings,  to  his  dress,  to  his  physical  needs.  He  grows  anesthetic 
and  analgesic.  The  cutaneous  reflexes  are  markedly  diminished.  The 
pupils  are  widely  dilated,  and  react  but  sluggishly.  The  tendon-reflexes 
are  exaggerated.  There  are  no  delusions,  hallucinations,  or  illusions,  as 
a  ruh^,  though  in  some  rare  instances  there  may  be  some  transient  mani- 
festation of  such  symptoms.  The  immobility  is  flaccid  in  character, 
only  seldom  presenting  any  indication  of  spastic  tension.  For  hours 
and  days  he  will  stand,  sit,  or  lie  in  one  place.  He  is  usually  speech- 
less, but  if  an  attempt  is  made  to  utter  an  interjection  or  phrase,  the 
voice  is  so  low  as  to  be  little  more  than  the  movement  of  the  muscles  of 
articulation.  The  pulse  is  small  and  weak,  the  heart-action  retarded, 
the  temperature  subnormal,  the  respiration  shallow. 

A  peculiar  feature  of  the  condition  is  the  occurrence  of  sudden  epi- 
sodic periods  of  excitement,  with  a  certain  amount  of  exaltation  lasting 
an  hour  or  two,  in  which  the  patient  runs  about,  sings,  dances,  and  talks 
incoherently. 

There  are  forms  of  primary  dementia  which  are  more  or  less  compli- 
cated with  melancholia,  stuporous  paranoia,  and  neurasthenia. 

Course  and  Prognosis. — The  psychosis  lasts  from  a  few  months  to  a 
year  or  more,  and  about  three  in  five  gradually  recover.  Most  of  those 
who  recover  show  a  defect  of  memory  for  what  has  occurred.  Some 
cases  recover  incompletely,  and  some  undergo  an  imperceptible  tran- 
sition into  secondary  dementia. 

Diagnosis. — The  chief  difliculty  in  diagnosis  lies  in  the  differentia- 
tion of  apathetic  forms  of  melancholia  from  primary  dementia.  From 
the  expression,  attitude,  gestures,  and  speech,  one  determines  the  exist- 
ence of  the  anxious  state  or  hallucinations  which  lie  at  the  base  of 
melancholia  passiva  or  melancholia  attonita.  The  history  of  the 
patient  will  distinguish  congenital  or  acquired  idiocy  from  this  form 
of  insanity. 

Pathological  Anatomy. — No  physical  basis  has  been  established 
for  this  disease.     It  is  regarded  as  a  purely  functional  psychosis. 

Treatment. — Mild  cases  may  be  treated  at  home  under  propitious 
conditions.  At  the  same  time,  most  of  these  patients  are  better  off  in 
asylums,  where  the  discipline,  regular  life,  and  expert  care  favor  speedy 
recovery.  Rest  in  bed  and  overfeeding  are  requisite  at  first.  Regular 
hydrotherapeutic  measures  are  of  value  (at  first  short  warm  baths,  later 
on  showers  and  spinal  douche).  Medicines  are  of  no  especial  value 
except  in  the  episodic  periods  of  excitement,  when  the  bromids  may  be 
employed,  together  with  hot  wet-packs. 


808  MENTAL  DISEASES. 


CHAPTER  XI. 
PARALYTIC  DEMENTIA. 

Synonyms. — Dementia  paralytica  ;  Progressive  geueral  paralysis  ;  Greneral  paresis  ; 
General  paralysis  of  the  insane. 

Definition. — Paralytic  dementia,  as  its  name  implies,  is  a  disorder 
characterized  chiefly  by  progressive  enfeeblement  of  the  mind,  together 
with  a  progressive  general  paralysis  of  the  whole  body.  It  is  essen- 
tially a  cortical  disease,  but  its  symptomatology  is  frequently  modified 
by  spinal  complications.  The  psychic  symptoms,  in  addition  to  the 
characteristic  progressive  dementia,  present  multiform  phases,  neu- 
rasthenic, hysterical,  hypochondriacal,  melancholic,  maniacal,  circular, 
paranoiac,  etc.  An  exjjansive  phase  with  delusions  of  grandeur  is  very 
common  at  one  period  or  another  in  the  course  of  the  malady. 

Etiology. — Intellectual  overwork  or  strain,  working  on  a  founda- 
tion impaired  by  syphilis  or  alcoholism,  or  both,  may  be  said  to  be  the 
chief  cause  of  general  paresis.  Heredity,  undoubtedly,  plays  a  part  in 
the  causation  of  this  form  of  mental  disorder,  though  perhaps  not  so 
great  as  in  other  classes  of  insanity.  The  role  of  heredity  has  been 
variously  computed  at  from  ten  to  forty  per  cent.  As  regards  sex,  it  may 
be  stated  that  on  an  average,  among  all  classes  of  society,  twelve  times  as 
many  males  as  females  are  affected — the  disproportion  seems  to  be  less 
among  lower  orders  of  people.  The  age  of  onset  is  usually  during  the 
fourth  or  fifth  decad,  bespeaking  in  general  the  climacteric  period  of 
human  life.  But  general  paralysis  may  be  encountered  at  almost  any 
age.  Nearly  one  hundred  cases  have  been  recorded  as  occurring  in 
children.  Occasionally  late  cases  are  met  with  after  the  age  of  sixty. 
It  is  a  common  disease  in  the  great  centers  of  civilization,  where  the 
intellectual  stresses  are  most  severe,  and  is  comparatively  rare  among 
lower  races.  For  instance,  it  is  seldom  observed  among  the  native 
Egyptians  or  Icelanders.  The  disease  is  more  frequent  among  men  of 
ability  in  professional  or  business  life  than  among  the  ignorant  and  un- 
cultured. 

As  regards  the  position  of  syphilis  as  an  etiological  factor,  it  may  be 
said  that  a  certain  history  of  syphilis  is  obtainable  in  at  least  fifty  per 
cent,  of  the  cases,  and  it  is  probable  that  the  true  relation  is  considera- 
bly larger.  Several  years  ago,  in  a  study  of  this  subject,  I  examined 
the  contributions  of  no  fewer  than  seventy  authors  to  the  elucidation  of 
this  problem.  There  was  wide  divergence  in  the  statistics  presented ; 
but  from  my  examination  of  all  these  figures,  it  was  assumed  that  be- 
tween sixty  and  seventy  per  cent,  of  all  cases  of  general  paralysis  were 
syphilitic,  if  not  far  more. 

By  a  comparison  of  statistics  of  the  relation  of  syphilis  to  all  other 
forms  of  insanity,  which  I  have  estimated  to  be  from  six  to  ten  per 
cent.,  we  have  tlie  further  fact  that  syphilis  is  seven  to  ten  times  as  fre- 
quent in  dementia  paralytica  as  in  insanitv  in  general. 


PARALYTIC  DEMENTIA.  809 

The  fact  is  thus  established  beyond  dispute  that  syphilis  is  a  striking 
etiological  factor  in  general  paresis,  and  many  modern  authorities  have 
come  to  look  upon  it  as  a  true  ])arasyphilitic  disease. 

A  nnich  more  difficult  problem  is  to  determine  the  exact  nature  of 
the  relationship  between  syphilis  and  general  paresis.  Is  it  a  direct 
cause,  or  merely  a  contributing  agent?  Is  it  in  syphilitic  cases  a  post- 
syphilitic affection,  or  is  foregone  syphilis  merely  a  predisposing  factor? 
The  problem  may  be  examined  from  several  standpoints.  In  the  first 
place,  we  have  the  rather  remarkable  statistics  of  Lewin  of  20,000 
cases  of  syphilis,  one  per  cent,  of  which  became  insane,  and  in  which 
not  a  single  case  of  general  paresis  developed.  Then  we  have  the 
further  fact,  to  which  I  have  already  alluded,  that  among  the  native 
Egyptians,  where  syphilis  is  one  of  the  most  wide-spread  of  disorders, 
scarcely  a  case  of  general  paresis  has  been  reported  ;  and  in  the  asylums 
at  Cairo,  which  I  visited  a  few  years  ago,  not  one  such  case  was  to  be 
found.  It  is  significant,  by  the  way,  tliat  alcoholism  is  seldom  or  never 
observed  among  them,  the  drinking  of  spirituous  liquors  being  inter- 
dicted by  the  Koran.  Such  facts  as  these  it  is  impossible  to  reconcile 
with  a  hypothesis  ascribing  to  syphilis  the  direct  causation  of  paralytic 
dementia. 

Again,  from  the  pathological  standpoint,  it  is  well  known  that  the 
direct  invasion  of  the  brain  by  syphilis  is  characterized  by  changes  in 
the  blood-vessels  (endarteritis  obliterans),  by  the  formation  of  gum- 
mata,  or  by  diffuse  meningeal  infiltration  (specific  leptomeningitis  or 
meningo-encephalitis).  The  first  and  third  of  these  processes  are  most 
frequent  in  and  about  the  base  of  the  brain.  The  second  is  more  com- 
mon in  cortical  regions.  On  the  other  hand,  in  general  paralysis  we 
have  a  chronic  meningitis  of  the  convexity  with  atrophy  of  the  cortex, 
and  the  processes  in  this  disease  and  in  syphilis  are  quite  distinct, 
although  there  are  cases  in  which  a  syphilitic  meningo-encephalitis  may 
closely  simulate  symptomatically  dementia  paralytica.  The  pathological 
processes  are  different. 

The  best  recent  English  exposition  of  the  relationship  of  syphilis  to 
general  paresis  is  by  Dr.  Frederick  Mott,  in  the  "Arch,  of  Neurology," 
published  by  the  Pathological  Laboratory  of  the  London  County  Asylums, 
Vol.  I.  He  does  not  consider  the  dictum  "  no  syphilis,  no  general 
paralysis,"  proven,  but  believes  all  the  evidence  is  in  favor  of  the  strong 
influence  of  syphilis  in  its  production,  and  brings  forward  this  evidence 
in  a  convincing  way.  One  of  the  most  cogent  reasons  is  to  be  found  in 
his  study  of  twenty-two  cases  of  juvenile  general  paralysis  occurring 
from  the  age  of  eight  to  twenty-three  years.  Syphilis  could  not  be  ex- 
cluded in  any  of  these,  but  was  positively  determined  to  be  present  in 
thirteen  cases,  and  in  the  parents  in  four,  making  a  total  of  eighty  per 
cent.  He  feels,  however,  that  all  were  syphilitic.  Dr.  Mott  considers 
the  pathological  process  in  both  tabes  and  general  paralysis  to  be  ident- 
ical, and  agrees  with  M5bius,  who  calls  them  raetasyphilitic,  the  same 
disease  affecting  different  parts  of  the  nervous  system.  Since  my  own 
studies  of  this  subject  in  1892,  I  have  devoted  more  than  usual  atten- 
tion to  an  extremely  careful   examination  of  the  history  and   of  the 


810  MENTAL   DISEASES. 

bodily  conditions  in  paretics  in  whom  sy^^hilis  was  denied,  and  feel  sure 
that  the  percentage  is  much  higher  than  the  figures  given  by  me  at  that 
time.  There  are  still  some  few  cases  in  which  it  is  not  possible  to  dis- 
cover, either  upon  the  person  or  in  the  history,  any  evidence  of  previous 
syphilis,  but  we  know  that  patients  are  often  seen  in  whom  the  specific 
infection  has  been  so  mild  in  character  that  no  residua  are  left  upon  their 
persons,  and  they  have  no  memory  of  initial  lesions,  yet  the  conditions 
are  such  that  they  must  have  had  syphilis.  As  Mott  says,  women,  for 
instance,  are  often  infected  and  have  no  characteristic  lesions.  They 
may  be  immunized  by  a  spermatically  infected  fetus,  so  that  they  have 
the  disease  in  so  mild  a  form  that  there  is  no  noticeable  impairment  of 
health. 

Alcohol  would  seem  to  be  a  factor  in  some  twenty  per  cent,  of  joar- 
etics.  Other  toxic  agents  (lead,  tobacco,  rheumatism,  etc.)  are  also  be- 
lieved to  take  a  part  at  times  in  the  etiology.  Trauma  has  often  been 
mentioned  as  an  occasional  cause  of  paresis,  but  there  is  no  well-authen- 
ticated instance  in  literature  of  such  etiology,  and  until  better  evidence 
is  oiFered  we  must  doubt  the  sufficiency  of  this  factor. 

In  most  cases,  as  already  intimated,  several  of  the  causes  named  are 
associated  in  the  production  of  the  disease. 

Symptomatology. — The  disease  is  best  studied  in  its  three  stages 
— the  prodromal  period,  the  established  disorder  (which  may  be  exalted, 
depressed,  or  hallucinatory),  and  the  terminal  period  of  dementia. 

Prodromal  Period. — General  paresis  is  one  of  the  most  insidious 
forms  of  insanity  as  regards  its  gradual,  almost  unnoticeable  onset. 
Very  often  this  early  stage  presents  symptoms  which  lead  to  its  being 
mistaken  for  neurasthenia.  Indeed,  the  earliest  symptoms  may  be 
neurasthenic  in  character,  or  even  a  combination  of  hysteria  with  neu- 
rasthenia. Sleeplessness,  tremor,  irritability  of  mood,  hypochondriacal 
depression,  dull  headache,  ophthalmic  migraine,  pains  in  various  parts 
of  the  body,  general  malaise,  loss  of  appetite,  and  digestive  disorders — 
these  are  the  manifestations  which  may  be  readily  misinterpreted  as 
purely  of  functional  nature.  It  is  only  when  other  symptoms  in  ad- 
dition to  these  are  presented  that  a  suspicion  of  a  more  serious  malady 
may  be  entertained  or  the  diagnosis  actually  established.  These  symp- 
toms are,  on  the  mental  side  :  little  faults  of  memory  ;  errors  in  speech  or 
writing ;  the  misuse  of  words ;  the  leaving  out  of  letters,  syllables,  or 
words,  or  their  reduplication  in  writing ;  growing  indifference  to  the 
higher  sentiments  ;  loss  of  the  critical  faculty  ;  small  lapses  in  the  pro- 
prieties, and  failure  of  interest  in  the  more  important  affairs  of  life.  As 
these  mental  features  become  more  and  more  pronounced,  the  patient 
loses  and  mislays  things,  makes  mistakes  in  money  matters,  errs  in  ap- 
pointments, confuses  persons  and  objects,  forgets  his  way,  becomes 
easily  angered,  markedly  offends  the  proprieties,  shows  extravagance  in 
the  use  of  money,  evinces  distinct  loss  of  the  ethical  feelings,  exhibits 
proclivities  to  sexual  and  alcoholic  excess,  and  becomes  negligent  of  his 
dress. 

In  the  earlier  period  the  patient,  like  any  neurasthenic,  has  a  dis- 


PARALYTIC  DEMENTIA.  811 

tinct  consciousness  of  his  own  illness  and  observes  his  symptoms.  But 
with  the  progress  of  the  malady — and  it  is  in  this  that  we  find  an  im- 
portant contrast  to  the  course  of  neurasthenia — he  loses  that  sense  of 
being  ill,  takes  no  further  notice  of  his  own  symptoms.  On  the  physical 
side  there  are  a  number  of  significant  marks  which  are  helpful  in  mak- 
ing an  early  diagnosis  :  defective  innervation  of  one  side  of  the  face, 
causing  a  slight  paralysis  ;  transitory  ocular  palsies,  diminished  sensibility 
to  pain,  Argyll-Robertson  pupils ;  diminished,  lost,  or  exaggerated 
tendon-reriexes  ;  a  dark,  pale,  greasy  complexion  ;  lack  of  facial  expres- 
sion ;  jerky  tremor  of  the  faciolingual  muscles  at  the  beginning  of 
voluntary  movement ;  slight  difficulties  of  articulation ;  rushings  of 
blood  to  the  head,  and  attacks  of  syncope  or  of  mild  or  severe  epilepti- 
form convulsions.  A  number  of  other  early  symptoms  have  been 
described  by  various  authors  to  which  some  value  attaches  :  loss  of 
memory  of  localization  of  tactile  sensations  (Ziehen)  ;  loss  of  the 
cremasteric  reflex  ;  testicular  insensibility  ;  peculiar  respiration,  with 
short  inspirations,  followed  from  time  to  time  by  prolonged  sigliing 
expirations  (R^gis) ;  gastric  and  vesical  crises  (Hurd) ;  calcification  of 
the  sternum,  with  incurvation  of  the  xiphoid  appendix  and  consequent 
interference  with  thoracic  breathing  (Regis). 

Period  of  Establishment  of  the  Disease. — When  the  disorder  is 
fully  established  after  a  prodromal  period  which  may  range  over  months 
or  years,  it  is  marked  by  both  physical  and  mental  symptoms  which  are 
usually  characteristic  : 

Chief  Physical  Symptoms. — (1)  Peculiar  articulation  and  writ- 
ing— the  "  paretic  speech  "  and  "  paretic  writing  "  ;  (2)  tremor  ;  (3) 
pupillary  disorders  ;  (4)  lost  or  exaggerated  tendon-reflexes  ;  (5)  mus- 
cular weakness  ;  (6)  apoplectiform  and  epileptiform  crises  ;  (7)  emacia- 
tion ;  (8)  trophic  disorders. 

Mental  Symptoms. — (1)  Failure  of  memory  for  both  recent  and 
old  events ;  (2)  diminishing  number  of  concrete,  abstract,  special  and 
general  ideas  ;  (3)  weakening  of  judgment ;  (4)  loss  of  sense  of  time 
and  place  (lack  of  orientation) ;  (5)  delusions  (marked  by  enormous 
exaggeration,  whether  exalted  or  depressed) ;  (6)  hallucinations  and  illu- 
sions ;  (7)  emotional  irritability  ;  (8)  exalted,  sometimes  depressed, 
mood ;  (9)  loss  of  ethical  and  esthetic  feeling. 

We  will  now  examine  these  symptoms  somewdiat  in  detail. 

The  paretic  speech  is  so  characteristic  that,  heard  a  few  times,  it  is 
always  remembered  ;  yet  it  is  difficult  to  describe.  There  are  shades 
of  diff'erence  in  various  individuals,  so  that  authors  cpialify  the  disorder 
of  speech  as  drawling,  stammering,  hesitating,  scanning,  spasmodic, 
ataxic,  and  so  oiT.  It  has  some  resemblance  to  the  speech  of  a  drunken 
man.  Doubtless  the  main  seat  of  the  lesion  aff'ecting  the  speech  of  the 
paretic  is  in  the  cortical  motor  speech-center,  but  sometimes  the  lesion 
is  probably  in  the  bulbar  centers  connected  with  the  elaboration  of  the 
motor  impulses  requisite  to  articulation.  The  jerky  tremor  or  ataxia 
of  the  speech-muscles,  together  with  incoordinated  impulses  from  the 
cortical  motor  speech-center,  is  responsible  for  the  peculiarities  in 
speech.     Lal)ials  and  certain  consonants  are  the  most  difficult  for  the 


812  MEXTAL   DISEASES. 

paretic  to  enunciate,  and  the  typical  speech  is  shown  in  the  attempt  to 
pronounce  such  words  or  phrases  as  "  electricity,"  "  artillery  and  cav- 
alry brigade,"  "  immovability,"  etc.,  in  which  the  consonants  may  be 
left  out,  drawled  over,  misplaced,  or  even  reduplicated  thus  :  "  elec- 
tericity,"  "  artillililery,"  "  bigrade,"  "  immobilty."  As  the  disease 
advances,  the  words  are  run  more  and  more  together,  until  finally  the 
speech  is  utterly  incomprehensible. 

The  handwriting  of  the  patient  is  of  equal,  and  in  the  earliest 
stages  even  of  greater,  importance.  Lapses  of  words,  repetitions  of 
words  or  even  sentences,  and  especially  elisions  and  reduplications  of 
letters  or  syllables  are  extremely  significant. 

The  tremor  in  paretics  affects  all  parts  of  the  body,  but  is  especially 
noteworthy  in  the  face  and  tongue.  In  the  tongue  it  often  takes  on  a 
fine,  fibrillary  character.  It  is  very  rare  in  even  pronounced  neuras- 
thenic conditions  to  observe  tremor  of  the  facial  muscles.  Still  we  do 
meet  with  it  at  times,  and  the  distinction  that  I  would  draw  between 
the  facial  tremor  of  profound  neurasthenia  and  that  of  paresis  is  that 
in  the  latter  disorder  there  is  a  peculiar  jerkiness  and  ataxia  in  the 
tremor,  especially  at  the  beginning  of  a  voluntary  movement.  Thus,  in 
asking  the  paretic  to  wrinkle  his  forehead,  an  ataxic  tremor  will  be  set 
up  in  the  occipitofrontalis.  In  snarling  up  the  nose,  it  is  observed  in 
the  small  muscles  about  the  cheek  and  nose.  In  showing  the  teeth,  the 
ataxic  tremor  becomes  marked  in  the  levators  of  the  lip.  In  protrud- 
ing the  tongue,  there  is  a  rapid,  jerky  tremor  at  the  beginning  of  the 
movement. 

As  regards  the  pupils,  the  most  important  sign  is  absence  of  the 
reflex  to  light.  Next  in  order  comes  extreme  miosis  (pin-hole  pupils), 
and  next  in  importance  a  variable  inequality  (one  pupil  being  larger  at 
one  time  and  the  other  at  another  time).  Irregularity  of  outline  of 
either  or  both  pujjils  is  significant.  Simple  inequality  of  the  pupils  is 
less  distinctive  because  met  with  in  other  forms  of  insanity,  and  occa- 
sionally in  normal  persons.  Marked  mydriasis  is  very  common  in  the 
latest  stage  of  the  disease. 

In  tabic  forms  of  the  disorder  the  knee-jerks  are  diminished  or  lost. 
In  all  other  forms  the  tendon-reflexes  are  apt  to  be  enormously  exag- 
gerated, so  that  we  get  not  only  extreme  knee-jerks,  but  quadriceps 
clonus,  ankle-clonus,  jaw-jerk,  jaw-clonus,  and  extreme  wrist-  and  elbow- 
jerks.  With  this  spastic  condition  we  observe  also  considerable  rigidity 
of  the  muscles,  with  a  tendency  in  the  latest  stage  to  marked  contrac- 
tures. Often  in  tabic  forms,  when  the  knee-jerks  are  at  first  lost,  they 
become  finally  exaggerated.  Hence,  while  the  term  tabic  is  often  used 
to  describe  a  form  of  paresis  in  which  we  have  lost  or  diminished  knee- 
jerks,  together  with  Argyll-Robertson  pupils,  this  is  simply  a  descriptive 
designation,  and  does  not  necessarily  imply  that  we  have  a  comlnnation 
of  locomotor  ataxia  with  paresis. 

As  previously  stated,  one  of  the  chief  symptoms  of  paralytic  de- 
mentia is  a  progressive  weakening  of  the  muscles  in  general  of  the 
whole  body.  It  is  rather  an  enfeel^lement  than  a  paralysis.  It  is 
manifested  mainly  by  localized  pareses  in  various  muscles  or  groups  of 


PARALYTIC  DEMENTIA.  813 

muscles.  These  are  often  noted  as  early  symptoms — for  instance,  in  the 
eyes  and  face.  In  fully  one-half  of  the  cases  we  observe,  at  one  time 
or  another,  weakness  of  some  of  the  ocukir  muscles,  not  infrequently 
giving  rise  to  diplopia  or  ptosis,  rarely  nystagmus.  A  certain  amount 
of  ptosis  is  often  seen,  and  the  overaction  of  the  occipitofrontalis  in 
consequence  forms  a  striking  picture  in  many  cases.  One-sided  paresis 
of  the  forehead  muscle,  orbicularis  palpebrarum,  or  lower  face  is  rather 
common.  The  muscles  about  the  mouth  are  particularly  often  involved, 
so  that  marked  inequality  of  the  nasolabial  fold  and  of  all  of  the  oral 
movements  is  encountered.  The  speech  has  frequently  a  nasal  tone 
from  one-sided  or  double  palate  paralysis.  Deviation  of  the  tongue  is 
common.  The  general  strength  of  the  extremities,  as  measured  by  dyna- 
mometers, is  diminished,  sometimes  on  one  side  more  than  on  the  other, 
presenting  the  picture  of  a  hemiparesis.  The  want  of  equal  innervation 
is  sometimes  indicated  by  the  attitude  of  the  patient,  the  inclination  of 
the  body  to  one  side  or  another,  backward  or  forward,  sinking  of  the 
head  on  the  breast,  etc.  Weakness  in  the  muscles  of  deglutition  leads  to 
difficulty  in  swallowing.  The  peculiarity  of  most  of  these  paralytic  phe- 
nomena is,  in  the  first  place,  their  miklness  of  degree,  and,  in  the  second, 
their  frequently  transitory  character  (the  weakness  may  be  first  on  one 
side  of  the  face,  then  on  the  other,  now  about  one  eye,  now  in  an  ex- 
tremity, etc.). 

Nearly  every  case  of  general  paresis  exhibits,  at  some  time  in  its 
course,  convulsive  or  apoplectiform  seizures.  Usually  these  critical 
episodes  occur  at  the  height  of  the  disorder  or  in  its  final  stages,  but 
occasionally  they  are  among  the  very  earliest  symptoms.  For  instance, 
one  case  that  came  under  my  observation  began  with  a  transitory  hemi- 
plegia following  an  apoplectiform  attack.  Up  to  the  day  before  this 
seizure  he  had  performed  his  difficult  duties  as  an  accountant  in  a  large 
railroad  organization  to  the  perfect  satisfaction  of  his  superiors,  and 
none  of  his  family  had  observed  any  indication  of  prodromal  symptoms. 
He  died  as  a  typical  paretic  a  year  later.  Another  case,  much  the  same 
in  many  ways,  began  with  general  epileptiform  convulsions  extending 
over  twenty-four  hours.  The  attacks  may  appear  in  the  form  of  syn- 
cope, or  coma,  or  aphasia.  A  peculiarity  of  all  of  these  crises  is  their 
transient  character,  and  as  even  in  cases  terminating  fatally  in  such 
attacks  often  no  lesion  has  been  found,  their  pathogeny  has  been 
ascribed  to  congestive  conditions  or  to  circumscribed  edemata  in  various 
areas  of  the  brain.  As  a  rule,  mental  failure  becomes  more  apparent 
after  these  crises. 

Rapid  emaciation  is  usual  after  the  disorder  has  actually  set  in, — that 
is,  at  the  termination  of  the  prodromal  period, — but  later  on,  after  the 
climax  has  been  reached  and  dementia  becomes  more  apparent,  patients 
often  gain  largely  in  flesh. 

Among  the  trophic  disorders  we  note  especially  bed-sores,  which 
appertain  mostly  to  the  terminal  condition.  In  some  of  the  cases  a  true 
trophoneurosis  is  the  cause,  and  in  others  weakened  peripheral  circula- 
tion and  uncleanliness.  A  striking  fragility  of  the  bones  is  common  in 
general  paresis,  which  accounts  for  numerous  accidents  in  asylums,  su(!h 


814  MENTAL   DISEASES. 

as  fractures  of  the  ribs  and  other  bones,  exploited  so  often  in  the  news- 
papers as  due  to  the  assaults  of  attendants.  I  have  known  a  maniacal 
paretic  to  break  all  of  the  small  bones  of  his  hand  by  pounding  on  a 
door.  Hematoma  of  the  ear  is  very  frequent  in  paralytic  dementia, 
and  this  must  be  ascribed  to  trophic  changes  in  the  vascular  walls,  per- 
mitting some  trivial  trauma  to  cause  a  rupture  in  the  vessels  of  the  peri- 
chondrium. The  hair  frequently  becomes  rapidly  gray  in  paresis,  and 
this,  too,  is  doubtless  a  trophic  symptom. 

Among  other  physical  symptoms  occasionally  met  with  are  to  be 
mentioned  changes  of  temperature,  alluded  to  in  the  chapter  on  General 
Symptomatology,  intermittent  albuminuria,  propeptonuria,  glycosuria, 
acetonuria,  polyuria,  impotence,  and  vesical  and  rectal  weakness.  Gly- 
cosuria is  sometimes  an  early  symptom. 

As  regards  mental  symptoms,  the  gradual  and  progressive  failure  of 
memory,  and,  as  a  consequence,  the  progressive  depletion  of  the  store 


Fig.  311.— A  group  of  paretics.    Taken  to  show  exalted  and  melancholic  phases  (Dr.  Atwood). 

of  memory-pictures,  ideas,  idea-associations,  and  judgment-associations, 
are  the  most  noteworthy  features  of  the  disease.  The  most  complicated 
conceptions,  as  well  as  those  acquired  latest,  are  the  first  to  disappear. 
Abstract  ideas,  owing  to  their  complexity,  are  the  earliest  to  go.  The 
patient  loses  his  memory  for  dates,  for  the  events  of  to-day  and  yester- 
day, and  finds  difficulty  in  remembering  his  appointments  and  duties. 
A  very  early  loss  of  the  power  of  mental  computation  is  notable.  With  the 
progress  of  the  malady,  even  the  older  memories  and  concrete  ideas 
vanish  by  degrees.  The  patient  comes  to  have  no  knowledge  of  time, 
the  place  where  he  is,  or  of  the  friends  who  surround  him.  The  loss 
of  the  faculty  of  judgment  is  evident  at  an  early  period  in  his  failing 
observation  and  comprehension  of  his  own  symptoms.  Ordinarily 
there  is  a  retardation  of  the  flow  of  ideas,  particularly  marked  in  the 
melancholic  type  of  the  disease.  In  the  exalted  type  there  is  an  accel- 
eration of  the  flow  of  thought,  which  is  given  a  special  color  by  the 
mental  enfeeblement. 


PARALYTIC  DE3IENTIA.  815 

There  are  cases  which  run  their  course  without  delusions,  the  symp- 
toms then  being  merely  the  progressive  dementia  with  advancing  physi- 
cal debility.  But  in  a  considerable  proportion  of  paretics  delusions 
are  manifested,  usually  of  grandiose  character,  associated  with  more  or 
less  ideomotor  excitement  (sometimes  approaching  the  maniacal  condi- 
tion), and  occasionally  of  melancholy  character.  The  grandiose  ideas 
of  male  patients  are  concerned  with  wealth,  power,  glory,  size,  strength, 
position,  possessions,  and  of  female  patients  with  dress,  finery,  jewels, 
and  children.  At  an  early  period  these  grandiose  ideas  are  not  to  be 
distinguished  from  the  similar  fancies  of  many  cases  of  ordinary  acute 
mania.  But  when  the  judgment  becomes  weakened,  as  it  inevitably 
does,  a  pecidiarly  distinctive  character  is  given  to  the  paretic's  delu- 
sions. The  grandiose  delusions  take  a  magnitude,  an  enormity,  a  stu- 
pendousness  not  observed  in  any  other  form  of  insanity.  Wealth  is 
counted  in  decillions  of  worldfuls  of  gold.  The  patient  is  czar,  king, 
president,  queen,  God,  at  the  same  time.  His  penis  is  a  mile  long, 
his  testicles  large  diamonds.  He  will  bring  the  Pacific  Ocean  over 
the  Andes  to  make  the  largest  waterfall  in  the  world.  He  will 
move  the  asylum  buildings  on  a  road  of  gold  to  Washington.  He 
has  thousands  of  wives,  every  one  of  whom  bears  two  hundred  children 
nightly.  He  bestows  on  his  physicians  and  nurses  royal  orders,  duke- 
doms, writes  them  checks  for  enormous  sums  of  money,  etc.  When 
the  mood  of  the  patient  is  hypochondriacal  or  melancholic,  the  delu- 
sions retain  the  same  element  of  enormity  despite  their  unhappy 
contents.  He  states  that  he  is  impoverished  by  having  lost  billions  of 
dollars ;  he  is  committed  to  prison  for  thousands  of  years ;  he  weeps 
because  he  can  not  do  his  duty  to  the  nations  which  he  governs ;  there 
is  some  horrible  condition  of  his  bowels  which  requires  the  most  awful 
of  operations,  etc. 

There  are  some  cases  of  general  paresis  which  exhibit  alternating 
phases  of  melancholic  depression  and  ambitious  exaltation,  and  these  are 
described  as  paralytic  dementia  of  circular  type. 

Hallucinations  and  illusions  are  frequently  observed  in  general 
paresis.  They  have  more  or  less  relation  to  the  condition  of  exaltation 
or  depression  present  and  to  the  delusions  manifested.  Auditory  hallu- 
cinations are  the  most  common.  They  are  noted  even  in  the  early 
periods  of  the  disease,  but  are  generally  a  part  of  the  maximum  period. 
They  are  absent  in  the  final  stage. 

Emotional  irritability  and  changeability  are  generally  evident.  The 
patient  laughs  or  weeps  easily,  and  is  often  readily  angered. 

The  excesses,  sexual  and  alcoholic,  lapses  of  propriety,  etc.,  are  sig- 
nificant of  loss  of  esthetic  and  ethical  sensibility.  He  indulges  him- 
self freely  and  without  morality  (though  previously  moral),  drinks  im- 
moderately, steals,  and  squanders  his  own  and  others'  property.  As 
his  character  sinks  lower  and  lower  he  commits  all  sorts  of  shameless 
oifenses  against  decency. 

Before  passing  on  to  the  final  stage,  we  not  infrequently  encounter, 
in  the  course  of  the  disorder,  peculiar  interludes  of  recession  of  all  of 
the  symptoms.     These  are  known  as  remissions.     Remissions  last  from 


816 


3IENTAL  DISEASES. 


several  weeks  to  several  months,  as  a  rule,  occasionally  for  a  year  or 
more.  Very  striking  at  times  is  the  remarkable  improvement  to  be 
observed  in  a  remission.  This  may  attain  to  a  degree  making  it  almost 
impossible  to  discover  any  vestige  of  deviation  from  the  patient's  normal 
mental  health.  The  extraordinary  delusions  disappear,  the  maniacal  or 
melancholic  mood  vanishes,  the  symptoms  of  confusion  and  forgetfulness 
pass  away,  and  noteworthy  intellectual  lacunae  are  filled  again.  The 
patient  may  return  to  his  affairs.  It  is  very  rarely  that  marked  physi- 
cal stigmata  of  the  disorder  diminish  and  give  place  to  normal  con- 
ditions. After  a  time  the  old  symptoms  of  the  dread  malady  reassert 
themselves  and  its  fatal  progress  is  rebegun. 

Terminal  Period. — As  already  intimated,  there  are  cases  in  which 

there  is  merely  a  progressive  en- 
feeblement  of  mind  and  paresis  of 
body  from  beginning  to  end,  with 
none  of  the  excited  or  depressed 
conditions,  delusions,  hallucinations, 
remissions,  etc.,  just  described  ;  cases 
which  pass  by  gradual  stages  from 
tlie  prodromal  into  the  terminal 
period.  In  the  main,  however,  we 
have  most  of  these  other  manifesta- 
tions interpolated.  The  final  stage 
is  often  ushered  in  by  the  convul- 
sive or  apoplectiform  seizures.  This 
is  the  stage  of  more  or  less  com- 
plete dementia.  We  may  still  note 
the  remains  of  old  grandiose  or 
hypochondriacal  delusions  in  the 
scarcely  comprehensible  mumblings 
of  the  paretic  dement,  but  usually 
the  mind  becomes  completely  vacu- 
ous ;  the  patient  speechless,  filthy 
in  his  habits,  bedridden,  and  more 
helpless  than  an  infant.  He  lies  in 
bed,  either  motionless  or  restlessly 
moving  his  limbs  and  grinding  his- 
teeth.  He  can  scarcely  swallow  his  food,  and  often  requires  to  be  fed 
to  prevent  strangling.  He  wets  and  soils  himself,  and  bed-sores  and 
contractures  develop.  Finally,  death  by  inhalation-pneumonia,  septi- 
cemia (from  the  bed-sores),  cystitis,  marasmus,  intestinal  catarrh,  or  ex- 
haustion steps  in  to  draw  the  curtain  on  the  distressing  picture.  Not  a 
few  die  at  an  earlier  period  in  an  epileptiform  or  apoplectiform  crisis. 

Duration  and  Prognosis. — Paralytic  dementia  runs  its  course  in 
three  to  five  years,  on  an  average.  There  are  more  cases  which  termi- 
nate under  three  years  than  over  five,  but  cases  lasting  five  years  are 
not  infrequent.  A  duration  of  ten  years  is  among  the  greatest 
rarities. 

The  prognosis  is  practically  always  death  within  a  short  term  of 


Fig.  312. — A  noted  actor  who  recently  died 
of  paresis.  Taken  to  show  the  expression  of 
paralytic  dementia  in  an  unusually  exjiressive 
face  (loaned  by  Dr.  Atwood). 


PARALYTIC  DEMENTIA. 


817 


years.  The  author  lias  never  known  personally  of  a  case  recovering. 
In  our  whole  literature  there  are,  according  to  Ziehen,  but  a  dozen 
cases  of  recovery  on  record.  It  is  probably  questionable  if  even  these 
were  genuine  cases  of  paresis,  since  an  error  in  diagnosis  is  not  at  all 
uncommon. 

Diagnosis. — The  chief  disorders  which  may  be  confused  with 
paralytic  dementia  during  the  various  stages  of  its  evolution  are 
neurasthenia,  alcoholism,  syphilis  of  the  central  nervous  system,  acute 
mania,  epileptic  dementia,  paranoia,  or  secondary  paranoia  with  delusions 
of  grandeur,  multiple  sclerosis,  and  mental  conditions  associated  with 
common  organic  lesions  of  the  brain  (tumor,  hemorrhage,  embolism, 
thrombosis).  In  atypical  cases  the  diagnosis  is  often  difficult  and 
sometimes  even  impossible. 

As  regards  neurasthenia,  it  is  only  in  the  prodromal  period  of  gen- 
eral paralysis  that  dilierentiation  may  be  difficult.  I  shall  attempt  to 
present  in  brief,  tabular  form  the  distinctive  diagnostic  points  of  these 
two  conditions  : 


General  Paresis  (Early  Period). 

Sluggish,  immobile,  irregular,  pin-hole, 
or  unequal  pupils. 

Diminished,  greatly  exaggerated,  or  mi- 
equal  knee-jerks. 

Fibrillary  tremor  of  tongue ;  jerky, 
ataxic  tremor  of  fingers,  face, 
tongue,  occipitofroutalis. 

Elision  or  reduplication  of  letters,  syl- 
lables, or  words  in  writing. 

Sometimes  noticeable  characteristic  de- 
fects in  speech. 

Usually  little  or  no  notice  taken  by  the 
patient  of  his  symptoms. 

In  some  cases  a  feeling  of  cheerfulness 
and  well-being  out  of  proportion  to 
the  actual  disorder  present. 

In  many  cases  a  vague,  hypochondriacal 
depression  with  tearfulness,  not 
referred  to  any  definite  physical 
cause. 

Actual  evidence  generally  found  of  fail- 
ing memory,  defect  of  intellectual 
process,  weakened  judgment,  and 
loss  of  esthetic  and  ethical  feeling. 

Occasionally  epileptiform  or  apoplecti- 
form crises. 

Vertiginous  attacks  and  transitory  apha- 
sia of  mild  degi^e. 


Neurasthenia. 
Large  and  rather  active  pupils  usually. 

Active  and  equal  tendon-reflexes. 

Tremor  fine  and  rapid  of  fingers  and 
eyelids,  not  jerky,  very  rarely  in- 
volving face,  almost  never  the 
tongue  and  forehead. 

Nothing  abnormal  in  the  writing. 

No  changes  in  enunciation. 

Patient  pays  marked   attention  to  his 

symptoms. 
Patient  apprehensive   and   alarmed  at 

any  symptoms  present. 

When  hypochondriacal,  patient's  atten- 
tion fixed  on  some  definite  morbid 
process  which  he  believes  to  be 
going  on  in  his  system. 

No  evidence  of  mental  decay  or  loss  of 
esthetic  and  ethical  feeling. 


Nothing  of  this  kind  in  neurasthenia. 
Not  present  in  neurasthenia. 


In  chronic  alcoholism  we  may  have  presented  to  us  many  symptoms, 
such  as  tremor,  thick  speech,  mental  changes  and  defects,  epileptiform 
crises,  and,  where  rudimentary  polyneuritis  is  present,  lost  knee-jerks, 
which  may  simulate  the  syndrome  of  paralytic  dementia.  The  resem- 
blance is  sometimes  remarkably  close.  The  chief  diiferential  point  is 
the  great  improvement  and  often  recovery  which  take  place  in  alco- 
holic mental  disorder  on  withdrawal  of  the  alcohol.  With  abstinence 
52 


818 


MENTAL  DISEASES. 


the  speech  becomes  normal,  the  tremor  grows  less  or  disappears,  the 
knee-jerks  return,  epileptiform  attacks  cease,  defects  of  memory  are  no 
longer  perceptible.  If  hallucinations  are  present,  they  are  more  often 
visual  and  zooscopic  in  alcoholism,  while  generally  auditory  in  paresis. 
The  delusions  of  the  chronic  alcoholic  are,  as  a  rule,  suspicious  and  per- 
secutory. It  must  be  remembered  that  a  typical  general  paresis  may, 
however,  develop  on  the  basis  of  a  chronic  alcoholism. 

Aside  from  the  comparison  of  neurasthenia  with  the  prodromal 
period,  probably  the  mistaking  of  syphilis  of  the  central  nervous 
system  for  advanced  general  paralysis  is  the  most  common  error  in 
diagnosis.  The  two  disorders  have  so  much  in  common  that  their 
differentiation  is  often  only  possible  by  prolonged  observation  through 
the  whole  course  of  the  disease ;  and  if  the  paretic  dementia  should 
happen  to  progress  as  a  simple  dementia  with  none  of  the  character- 
istic episodes,  the  diagnosis  is  sometimes  quite  impossible.  The  follow- 
ing table  will  serve  to  make  some  of  the  similar  and  unlike  features  of 
the  two  maladies  apparent  : 


General  Paealysis. 

Paresis  of  mild  degree  of  cranial  nerves 
at  times.  Slow  in  onset  and  trans- 
itory. 

Symptoms  of  a  diffuse  general  lesion. 

Jerky  and  ataxic  tremor. 

Loss  of  iris  reflex  to  light,  preserva- 
tion of  movement  of  iris  in  accom- 
modation (Argyll-Robertson  pupil); 
extreme  miosis. 

Characteristic  elisions  and  reduplications 
of  letters,  syllables,  or  words  in  writ- 
ing. 

Peculiar  disorder  of  speech.  (G.  P. 
speech.) 


Headaches  vague,  transitory,  and  sel- 
dom distressing. 

No  material  changes  in  the  fundus. 

Progressive  advance  of  the  disease  to  a 
speedily  fatal  termination,  with  a 
possible  remission  in  some  instances 
for  a  brief  period. 

Delusions  often  expansive,  sometimes 
depressed,  characterized  by  enor- 
mous exaggeration  in  either  case. 

Affective  state  often  expansive,  some- 
times depressed. 

Progressive  mental  enfeeblement. 

Epileptiform  and  apoplectiform  crises  in 
nearly  every  case,  and  frequently  re- 
peated. 

Antisyphilitic  remedies  useless. 


Cerebrospinal  Syphilis. 

Complete  paralysis  of  one  or  several 
cranial  nerves  often.  Generally  sud- 
den in  onset  and  stable. 

Symptoms  of  multiple  lesions. 

No  tremor  in  syphilis. 

Iris  often  immobile  both  to  light  and  in 
accommodation ;  extreme  miosis 
very  infrequent. 

If  any  change  in  writing  at  all,  due  to 
agraphia  or  dementia.  No  resem- 
blance of  the  changes  to  those  of 
paresis.  _  . 

No  speech  disorder  usually,  but,  if  any, 
due  to  organic  aphasias  of  one  kind 
or  another.  No  resemblance  to  the 
G.  P.  speech. 

Headaches  extremely  severe,  constant, 
and  worse  at  night. 

Optic  neuritis  occasionally. 

Irregular  advance,  with  many  fluctua- 
tions in  intensity  and  character  of 
the  symptoms,  extending  over  a 
long  period  of  years,  and  not  neces- 
sarily fatal. 

Delusions  rarely  present. 


Affective  state  usually  depressed  or  apa- 
thetic. 

Incoherence  and  thought-inhibition. 

Epileptiform  and  apoplectiform  seizures 
uncommon,  but  if  they  do  occur,  are 
generally  single,  isolated  attacks. 

Antisyphilitic  remedies  of  marked  ser- 


A  gummatous  meningitis  may,  however,  present  a  typical  general 


PARALYTIC  DE3IENTIA.  819 

paresis  in  all  its  manifestations,  and  there  are  cases  in  which  the  actual 
lesions  of  paresis  exist  side  by  side  with  syphilitic  cerebral  lesions. 

We  may  have  maniacal  outbursts  in  the  course  of  general  paresis. 
Indeed,  I  have  seen  paresis  begin  in  a  number  of  instances  as  an 
apparent  acute  mania.  During  this  maniacal  state  the  chief  means  of 
diiferentiation  of  the  two  disorders  is  in  the  character  of  the  contents  of 
the  delusions.  Both  are  exalted  and  expansive  and  tend  to  the  same 
general  exaggeration  of  feelings  of  power,  strength,  intellectual  and 
physical  abilities,  wealth,  social  station,  etc.  But  the  stupendous  ex- 
aggeration in  general  paresis  is  never  observed  in  acute  mania.  This  is 
a  valuable  indication.  Naturally,  if  any  of  the  physical  signs  of  paresis 
are  present,  the  diagnosis  is  not  difficult. 

Epileptic  dementia,  with  its  slow  speech,  mental  defect,  and  epileptic 
seizures,  might  at  times  be  mistaken  for  a  paralytic  dementia,  presenting 
chiefly  these  symptoms.  But  the  history  of  long  years  of  epilepsy 
preceding  the  psychic  degeneration  suffices,  as  a  rule,  for  the  diagnosis. 
It  is  only  when  such  history  is  not  obtainable  that  error  might  arise. 

In  paranoia  itself,  and  in  paranoia  secondary  to  acute  mania  or 
melancholia,  the  expansive  or  depressed  delusions  are  of  a  more  fixed 
and  much  less  exaggerated  nature.  A  study  of  the  character  of  the 
delusional  contents  should  make  differentiation  easy. 

Multiple  sclerosis,  with  its  jerky  tremor,  exaggerated  reflexes,  and 
mental  enfeeblement  might  at  times  present  a  syndrome  analogous  to 
that  of  some  cases  of  paralytic  dementia.  The  tremor  of  multiple 
sclerosis,  however,  while  also  jerky  and  ataxic,  is  a  marked  intention 
tremor,  exhibiting  wider  and  wider  excursions  the  greater  the  effort  to 
carry  on  a  voluntary  movement.  The  tremor  of  paresis,  on  the  other 
hand,  shows  no  such  increasing  exaggeration  on  voluntary  efforts  to 
use  the  muscles.  In  sclerosis,  the  head  is  often  involved  in  the  tremor  ; 
in  paresis,  never.  Nystagmus,  so  common  in  sclerosis,  is  almost  never 
observed  in  paresis.  The  dementia  of  sclerosis,  when  present,  is  slight 
and  not  especially  progressive,  and  there  are  no  expansive  or  depressed 
delusional  episodes,  such  as  characterize  paralytic  dementia. 

Focal  brain-lesions  (tumor,  hemorrhage,  softening,  etc.)  with  de- 
mentia and  paralysis  may  simulate  somewhat  certain  types  of  general 
paralysis,  but  the  progressive  character  of  the  latter  disorder,  with  its 
crises  and  psychic  episodes,  should  serve  to  give  the  condition  presented 
definite  outline  and  character. 

Pathological  Anatomy. — It  is  usual  to  describe  the  pathological 
condition  underlying  paralytic  dementia  in  general  terms  as  a  diffuse 
meningo-encephalitis.  The  gross  changes  observed  at  autopsy  are  as 
follows  : 

1.  General  diminution  of  weierht  of  the  brain. 

2.  Increased  fluid  in  the  subdural  space  and  in  the  meshes  of  the 
arachnoid  (external  hydrocephalus). 

3.  Pachymeningitis  hsemorrhagica  interna,  with  large,  fresh,  or  old 
hematomata  of  the  dura  mater  (in  about  half  of  the  cases). 

4.  Chronic  leptomeningitis  (opacity  and  thickening,  with  adhesion 
of  the  membranes  to  the  cortex). 


820  MENTAL   DISEASES. 

5.  Xarrowing  of  the  cortex,  with  gaping  of  the  fissures. 

6.  Distention  of  the  ventricles  with  serum  and  granulated  and  thick- 
ened ependyma  (chronic  internal  hydrocephalus). 

7.  Gray  degeneration  in  the  centrum  ovale,  brain-axis,  in  various 
columns  of  the  spinal  cord,  and  in  some  of  the  spinal  roots  and 
peripheral  nerves. 

The   microscopical  findings  may  be  summarized  briefly  as  follows  : 

1.  Changes  in  the  vascular  walls,  dilatation  of  the  perivascular 
spaces,  wandering  white  and  red  blood-corpuscles. 

2.  Increase  in  number  of  the  astrocytes. 

3.  In  the  ganglion-cells  :  loss  of  the  nucleus  and  nucleolus,  cloudy 
swelling,  shrinking  of  the  protoplasmic  ]3rocesses. 

4.  Degeneration  and  disappearance  of  the  nerve-fibers  with  myeliu- 
sheaths,  in  the  white  matter  and  in  the  cortex,  and  of  the  tangential 
fibers. 

The  whole  cortex  is  more  or  less  aifected,  but  often  the  changes  are 
more  marked  in  one  area  than  in  another.  It  is  usual  to  find  the 
frontal  lobes  especially  implicated. 

Treatment. — In  the  majority  of  cases  of  general  paresis  commit- 
ment to  an  asylum  is  necessary,  owing  to  the  dangers  arising  from  the 
patient's  excesses.  He  may  squander  his  property  or  scandalize  his 
family  by  his  immoral  or  criminal  acts.  It  is  true  that  cases  which 
present  merely  the  dual  symptomatology  of  increasing  physical  debility 
with  progressive  mental  enfeeblement  may  be,  and  often  are,  treated 
at  home.  But,  on  the  whole,  it  is  better  to  act  promptly  in  placing  the 
patient  in  a  place  of  safety. 

The  disease  being  inevitably  fatal,  there  is  little  to  be  advised  in  the 
way  of  medication,  save  symptomatic  treatment.  It  is  quite  proper, 
in  cases  with  a  history  of  syphilis,  to  try  energetic  antisyphilitic  meas- 
ures— mercurial  inunctions  and  large  doses  of  iodid.  If,  by  any  pos- 
sibility, there  has  been  any  confusion  of  the  malady  with  cerebral 
syphilis,  this  will  at  least  serve  to  remove  any  doubt.  The  opium  treat- 
ment is  of  value  in  the  periods  of  depression,  and  hyoscin,  hyoscyamin, 
or  duboisin  (gr.  ywq  ^^  ^^-  eV)?  hypodermatically,  in  the  periods  of  mani- 
acal excitement.  Where  epileptiform  seizures  are  frequent  the  bromids 
are  indicated,  and  in  status  epilepticus  chloral  and  starch-water  per 
rectum  (gr.  xv  to  i^j  of  starch  water).  Chloral  combined  with  morphin 
is  to  be  recommended  in  phases  marked  by  hallucinatory  excitement. 

Little  or  nothing  is  to  be  expected  from  the  many  measures  advo- 
cated by  various  authors  :  setons  and  vesicants  to  the  nape  of  the  neck, 
painting  the  neck  with  iodin,  hydrotherapy,  physostigmin,  ergotin,  and 
trepanation. 

Trephining  has  been  resorted  to  a  number  of  times  in  the  past  six 
or  eight  years,  but  seems  to  have  been  abandoned  as  useless.  The 
theory  that  led  to  its  use  was  that  there  might  be  increased  intracranial 
pressure,  bat  this  theory  has  beeu  discarded  for  want  of  evidence. 

When  dysphagia  is  present,  the  patient  may  require  feeding  with 
the  tube.  In  the  terminal  period  of  the  disorder  catheterization  and 
careful  efforts  at  preventing  bed-sores  are  required. 


PARANOIA.  821 


CHAPTER   XII. 
PARANOIA. 

Synonyms. — Chronic    delusional    insanity ;     Progressive    systematized    insanity  ; 
Primare  Verriicktheit ;  old  term,  "Monomania." 

Definition. — Paranoia  may  be  defined  as  a  progressive  psychosis 
founded  on  a  hereditary  basis,  characterized  by  an  early  hypochon- 
driacal stage,  followed  by  a  stage  of  systematization  of  delusions  of 
persecution  which  are  later  transformed  into  systematized  delusions 
of  grandeur.  Though  hallucinations,  especially  of  hearing,  are  often 
present,  the  cardinal  symptom  is  the  elaborate  system  of  fixed  delu- 
sions. 

The  hypochondriacal  stage  is  called  by  R^gis  "  the  period  of  analytic 
concentration  "  ;  the  second  stage,  "  the  period  of  delusive  explication  "  ; 
the  final  stage,  "  the  period  of  transformation  of  personality." 

Varieties  of  Paranoia. — There  is  one  typical  form  of  paranoia 
to  which  the  main  portion  of  this  chapter  will  be  devoted,  because  it  is 
the  type  which  will  be  most  readily  recognized  by  the  student  and 
general  practitioner.  But  there  are  incomplete  or  immature  forms  and 
atypical  variations,  which  the  special  student  of  morbid  psychology 
learns  in  the  course  of  time  to  distinguish.  Thus,  many  of  those 
eccentric  or  queer  individuals  whom  we  call  "cranks"  are  rudimentary 
or  undeveloped  cases  of  paranoia.  Some  idea  of  the  varieties  of  para- 
noia noted  by  authorities  may  be  gathered  from  the  attempts  at  classifi- 
cation by  different  writers.  For  instance,  French  and  Italian  authors 
are  inclined  to  divide  paranoia  into  two  great  groups — viz.,  (1)  degenera- 
tive, with  original  and  late  subvarieties,  according  to  the  period  of 
life  at  which  the  insanity  develops  ;  (2)  psychoneurotic,  with  primary 
and  secondary  subvarieties,  according  to  whether  it  develops  primarily 
or  secondarily  to  another  insanity. 

Ziehen  classifies  paranoia  into  two  great  groups,  according  to  the 
predominance  of  either  delusions  or  hallucinations — where  hallucina- 
tions are  the  most  prominent  symptom,  he  terms  the  psychosis  paranoia 
hallucinatoria ;  where  delusions  are  preeminent,  he  denominates  it  para- 
noia simplex.  Either  form  may  be  acute  or  chronic.  Hence  he  makes 
four  chief  types  :  (1)  Paranoia  hallucinatoria  acuta  ;  (2)  Paranoia  hal- 
lucinatoria chronica ;  (3)  Paranoia  simplex  acuta  ;  (4)  Paranoia  sim- 
plex chronica.     - 

This  last  form  is  the  name  given  by  Ziehen  to  the  complete  typical 
form  of  paranoia  which  is  described  in  this  chapter,  and  which  he 
describes  as  having  four  stages  (prodromal,  persecutory,  expansive,  and 
pseudodemented).  Ziehen  also  specifies  several  varieties  of  acute  hal- 
lucinatory paranoia — viz.,  the  fleeting-idea  form,  the  stuporous,  the 
incoherent,  the  exalted,  and  the  depressive  forms. 

Krafft-Ebing  makes  two  great  divisions — original  paranoia,  appear- 


822  MENTAL   DISEASES. 

ing  in  early  childhood  or  before  puberty,  and  acquired  (tardive)  paranoia, 
appearing  between  the  ages  of  puberty  and  sixty  years.  The  latter 
class  he  subdivides  as  follows  : 

(A)  Paranoia  persecutoria  :  (1)  the  typical  form  ;  (2)  subtype 
(paranoia  sexualis)  ;  (3)  paranoia  querulans. 

(B)  Paranoia  expansiva  :  (1)  paranoia  inventoria  and  reformatoria  ; 
(2)  paranoia  religiosa ;  (3)  paranoia  erotica. 

Etiology. — Heredity  is  a  more  important  etiological  factor  in 
paranoia  than  in  any  other  form  of  insanity.  Kraift-Ebing  states  that 
he  has  never  seen  a  case  without  hereditary  taint.  Tanzi  and  Riva  found 
in  their  cases  of  paranoia  77  per  cent,  of  heredity  and  9.5  per  cent,  of 
infantile  cerebral  disorders,  while  in  the  remaining  14  per  cent,  hered- 
itary factors  could  not  be  ascertained,  but  were  not,  of  course,  ex- 
cluded. It  is  more  common  in  females  than  in  males.  It  affects  by 
preference  individuals  who  are  even  from  childhood  peculiar,  morbid, 
shy,  irritable,  mistrustful,  and  misanthropic.  It  is  very  common  to 
find,  in  cases  of  paranoia,  some  of  the  various  stigmata  hereditatis 
described  in  the  chapter  on  Etiology,  such  as  cranial  or  facial  asymmetry, 
malformations  of  the  ear  or  palate,  etc. 

Symptomatology. — We  will  examine  the  symptoms  of  the  different 
stages  in  the  order  of  their  development.  In  the  prodromal  peinod,  the 
hypochondriacal  stage  or  period  of  subjective  analysis,  as  it  has  been 
variously  termed,  which  may  have  its  conception  in  early  childhood,  the 
patient  is  morbidly  shy,  peculiar,  eccentric,  avoids  the  companionship 
of  others,  and  is  prone  to  withdraw  himself  into  the  solitude  of  his  own 
thoughts.  The  physiological  commotion  of  puberty  and  adolescence, 
with  its  inflow  into  consciousness  of  innumerable  new  sensations,  its 
flood  of  new  instincts,  powers,  ambitions,  and  ideas,  tends  to  intensify 
the  morbid  proclivities  already  evident.  The  patient  notes  his  own 
peculiarities  of  conduct,  and  begins  to  recognize  the  singularity  of  many 
of  the  somesthetic  sensations  which  come  to  him — sensations  which  at  this 
time  might  well  be  considered  more  or  less  neurasthenic  in  character  : 
paresthesias  of  the  head,  trunk,  viscera,  and  limbs ;  pains  in  various 
parts  of  the  body,  tinnitus  aurium,  sparks  and  dots  before  the  eyes,  and 
the  like.  The  unnaturalness  of  these  sensations  leads  to  his  spending 
much  time  in  contemplation  of  them,  so  that  a  hypochondriacal  com- 
plexion is  given  to  his  thoughts.  To  these  physical  sensibilities  are 
now  added  a  consciousness  of  difficulty  in  the  concentration  of  his 
thoughts ;  a  difficulty  in  the  proper  control  of  the  direction  and  subject 
matter  of  his  thoughts.  He  becomes  extremely  introspective,  and,  the 
more  he  studies  the  somesthetic  sensations  brought  to  his  attention,  the 
more  he  contemplates  the  phenomena  of  the  uncontrollability  of  his 
tlioughts,  of  their  rising  unbidden  from  his  subliminal  consciousness, 
of  the  unrestrained  constellation  of  his  presentations,  the  more  is  he 
inclined  to  search  for  some  cause  of  his  morbid  condition.  At  first, 
like  an  ordinary  hypochondriac,  he  investigates  himself  to  find  a  solu- 
tion of  the  problem,  and,  failing  in  that,  he  extends  the  region  of  his 
observation  to  his  environment,  seeking  there  the  reason  of  his  strange 
feelings,  general  disquietude,  and  morbid  stream  of  thought.     He  be- 


PARANOIA.  823 

comes  wholly  preoccupied  with  himself.  He  can  not  employ  himself, 
either  physically  or  mentally,  as  he  should.  He  fails  in  his  duties — 
in  everything  he  undertakes.  People  seem  strange  to  him  in  their 
conduct  and  in  what  they  say.  He  grows  suspicious  and  distrustful  of 
everything  and  everybody.  What  is  done  and  said  by  others  appears 
to  have  some  significant  relation  to  himself.  People  alter  in  their  con- 
duct toward  him,  look  at  him  curiously,  smile  sarcastically  when  he 
passes,  wink  at  or  make  signs  to  one  another  when  he  is  near ;  make 
observations  among  themselves  which,  overheard  by  him,  are  construed 
as  having  a  double  meaning,  as  being  derogatory  to  him,  reflecting  on 
his  character.  The  more  he  studies  the  extraordinary  condition  of 
affairs,  the  more  gloomy,  solitary,  and  self-absorbed  he  becomes. 
Naturally,  the  growing  alteration  in  himself  really  does  provoke  the 
notice  of  others — a  fact  which  tends  to  intensify  his  ever-increasing 
suspiciousness  of  concealed  animosity  among  those  with  whom  he  comes 
in  contact.  Many  things  in  his  past  life  rise  up  in  his  memory  to  find 
a  new  interpretation  in  the  light  of  his  present  general  distrust.  His 
physical  sensations  have  become  more  marked,  have  taken  on  a  new 
character,  have  altered  frwii  paresthesias  to  illusions,  and  even  hallucina- 
tions, of  general  or  special  sensibility.  He  feels  peculiar  general  sensa- 
tions, shooting  pains,  sudden  prickings  in  his  skin.  Unusual  and 
unpleasant  odors  or  tastes  harass  him.  Extraordinary  sensations  flow 
into  consciousness  from  his  genital  organs.  Much  more  serious  and 
remarkable,  however,  are  the  peculiar  changes  in  his  auditory  percep- 
tions. At  first  these  are  usually  confused  noises,  or  roaring  and 
tinkling  sounds,  with  the  gradual  perversion  of  sounds  and  words 
heard  into  illusions  colored  by  the  suspicious  contents  of  the  patient's 
consciousness  ;  later,  actual  hallucinations  of  hearing,  which  become  a 
fixed  and  permanent  feature  of  his  malady. 

The  patient  now  enters  into  the  second  or  persecutory  peinod  of 
paranoia,  the  period  of  delusional  explication  of  his  troubles.  He  has 
arrived  at  what  he  conceives  to  be  a  logical  result  of  his  reasonings,  a 
rational  explanation  of  the  distress  and  affliction  he  has  undergone. 
Everything  he  has  suffered  has  been  due  to  the  machinations  of  un- 
known enemies.  The  delusions  of  persecution  are  at  first  somewhat  con- 
fused in  character.  No  particular  individual  or  group  of  individuals  is 
thus  far  responsible  for  the  inflictions.  It  is  simply  some  unknown 
persons  who  take  pains  to  manifest  ill-will  or  malevolence  toward  him. 
"  They  "  talk  against  him,  call  him  names,  attempt  to  poison  him  with 
gases  or  by  tampering  with  his  food,  and  try  to  injure  him  with  electric 
shocks  or  by  throwing  corrosive  substances  at  him.  Since  wherever  the 
patient  may  be,  wherever  he  may  go,  the  voices,  shocks,  poisons,  etc., 
seem  to  pursue  him,  he  comes  to  think  that  no  single  person  could 
manage  so  vast  a  conspiracy.  It  must  be  some  large  aggregation  of 
persons  who  are  concerned  in  the  effort  to  humiliate,  cripple,  or  destroy 
him  ;  an  aggregation  bound  together  by  ties  of  secrecy,  and  able  to  per- 
meate all  classes  of  society.  What  could  such  body  be  but  a  secret 
society,  an  order  of  Masons  or  Odd  Fellows  ;  some  religious  or  political 
brotherhood — the  Jesuits,  Catholics,  Protestants,  anarchists,  or  police. 


824 


MENTAL  DISEASES. 


Perhaps  some  one  individual  is  at  the  head  of  the  band  of  plotters,  some 
arch-conspirator,  but  the  work  is  done  by  innumerable  aides,  who 
employ  all  manner  of  means  and  apparatus  to  accomplish  his  ruin. 
This  system  of  persecutory  ideas  is  built  up  in  the  most  elaborate  way, 
and  the  more  educated  the  individual  suifering  from  paranoia,  the  more 
wonderful  the  organization  and  adjustment  of  the  various  parts  of  the 
delusional  system.  The  persecutory  delusions  of  other  forms  of  psy- 
choses, such  as  toxic  insanity,  senile  dementia,  and  melancholia,  may 
have  a  certain  interest  and  fixity,  but  those  of  the  paranoiac  are  woven 
together  like  a  romance.  The  relation  of  the  former  to  the  latter  is  that 
of  the  brief  sketch  to  the  serial  novel.  The  telephone,  the  phonograph, 
telepathy,  hypnotism,  and  other  and  more  mysterious  apparatus   and 

phenomena  are  brought  into  service 
by  the  relentless  league.  I  do  not 
know  the  origin  of  Du  Maurier's 
conception  of  his  novel,  "  Peter 
Ibbetsen,"  but  I  suspect  that  many 
of  its  unique  features,  especially 
that  of  "  dreaming  true,"  were  sug- 
gested by  conversations  with  some 
well-educated  paranoiac  in  a  lunatic 
asylum. 

Many  patients  seek  in  a  most 
elaborate  way  to  explain  one  pecu- 
liarity of  their  auditory  hallucina- 
tions— viz.,  the  fact  that  their 
thoughts  are  read  off  by  the  voice 
or  voices  simultaneously  with  the 
appearance  of  the  thoughts  in  con- 
sciousness. This  adds  naturally  a 
new  terror  to  the  persecution,  for 
the  ability  of  the  conspirators  to 
read  off  and  taunt  the  patient  with 
his  own  most  secret  thoughts  is 
a  particularly  refined  species  of 
deviltry,  as  well  as  evidence  of  the 
extraordinary  psychological  power 
of  his  tormentors.  The  voice  which  speaks  his  thoughts,  or  answers 
his  thoughts  before  he  can  himself  utter  them,  may  be  referred  to  the 
external  world  or  to  some  part  of  his  own  body.  This  phenomenon 
has  been  variously  termed  echoing  of  the  thoughts,  motor  representation 
of  articulation,  and  verbal  psychomotor  hallucination.  It  depends  upon 
the  close  relation  existing  from  earliest  infancy  between  the  auditory 
word-center  and  the  motor  speech-center.  Any  irritation  of  this  audi- 
tory area  is  immediately,  synchronously,  irradiated  to  the  motor  speech- 
center.  However  slight  this  stimulation  of  the  speech-muscles,  recur- 
rent sensations  of  movement  in  them  are  carried  back  to  the  brain, 
giving  rise  to  the  hallucinations  of  internal  hearing. 

The  patient  is  driven  by  his  delusions   to  make  complaints  to  the 


Fig.  313. — Young  paranoiac  with  homicidal 
tendencies  at  period  of  passing  from  persecutory 
into  grandiose  stage  (Dr.  Atwood). 


PARANOIA. 


825 


police,  to  judges,  or  to  the  governor  of  the  State,  the  President,  or  other 
government  or  judicial  authorities.  Not  infrequently  he  attempts,  him- 
self, to  wreak  vengeance  upon  one  or  more  of  his  imaginary  enemies. 
Attempts  at  homicide  are,  therefore,  common  in  these  cases.  The 
writer  had  in  his  charge  at  the  Poughkeepsie  Asylum,  for  some  years, 
Ernest  Duborgue,  a  persecutory  paranoiac,  Avho,  many  years  ago,  ran 
through  Fourteenth  Street,  New  York,  stabbing  women  right  and  left 
with  a  pair  of  compasses.  More  often  they  seek  to  escape  from  their 
enemies  by  constant  change  of  residence. 

The  third  stage,  the  expansive  period,  or  the  period  of  transforma- 
tion of  personality,  is  often  induced  by  the  patient's  attempt  at  a  logical 
explanation  of  the  cause  of  the  persecution.  Since  he  has  so  many 
enemies,  and  every  man's  hand  is  against  him,  it  must  be  due  to  his 
importance.  He  either  resembles  some  distinguished  personage  or  he 
is  of  royal  or  god-like  descent.  The 
transformation  may  be  suddenly  induced 
by  a  hallucination  revealing  to  him  his 
high  estate.  The  contents  of  these 
delusions  of  grandeur  may  be  religious, 
political,  erotic,  jealous,  and  so  on. 
For  instance,  the  delusion  of  being 
a  prophet  or  a  second  Messiah  is 
very  common  (paranoia  religiosa).  The 
delusion  of  being  a  great  discoverer 
or  inventor  is  frequently  met  with 
(paranoia  inventoria).  Another  com- 
mon delusion  is  that  of  being  a  great 
social  reformer  (paranoia  reformatoria). 
A  peculiar  form  is  paranoia  erotica,  in 
which  a  person  imagines  him-  or  herself 
to  be  beloved  by  some  one  of  superior 
station.  It  is  a  romantic,  platonic  love 
in  which  the  patient  indulges.  He 
has  communications  with  the  object  of 
his  delusions,  imaginary  conversations, 

through  the  medium  of  hallucinations,  A  good  example  of  this  form  was 
that  of  Dougherty,  who  followed  Mary  Anderson  all  over  the  country, 
and  was  finally  sent  to  an  asylum  because  of  his  threats  to  kill  any  one 
who  interfered  with  his  attempts  to  gain  a  personal  interview  with  the 
famous  actress.  Measurements  which  I  made  of  his  head  show^ed  a 
pathological  excess  in  the  height  of  the  skull.  ^  After  his  commitment 
to  an  asylum  he  ^shot  one  of  the  physicians  who  had  him  in  charge. 
Another  interesting  variety  of  paranoia  is  that  observed  in  the  litiga- 
tionists  (paranoia  querulans),  who  occasionally  distinguish  themselves  by 
their  lifelong  involvement  in  legal  processes  (due  to  an  overwhelming 
egotism,  which  leads  to  a  continual  zealous  eifort  to  set  themselves  right, 
despite  the  advice  of  friends,  and  the  wasting  of  their  property,  after  the 

^  "Familiar  Forms  of  Nervous  Disease,"  by  M.  Allen  Starr,  New  York,   1890. 
Article  on  ' '  Paranoia, "  by  F.  Peterson,  page  299. 


Fig.  314. — Erotic  paranoia.   "  Mary  Ander- 
son's lover  "  (see  text;. 


826  MENTAL  DISEASES. 

loss  of  some  possibly  trivial  lawsuit).  Pretenders  to  thrones,  self-styled 
kings,  presidents,  princes,  and  so  on,  are  often  noted  among  paranoiacs 
who  have  reached  this  third  stage  of  evolution.  Quite  commonly  per- 
secutory ideas  still  remain  in  the  minds  of  these  patients  in  association 
with  the  delusions  of  grandeur. 

Each  of  these  periods  of  development  may  last  for  several  years, 
the  disorder  may  undergo  arrest  at  any  period,  and  there  may  be  varia- 
tions in  the  degree  of  development  of  any  stage ;  so  that  we  constantly 
meet  with  atypical  forms  of  paranoia.  An  excellent  condition  of 
memory,  judgment,  and  intellect  in  all  other  directions  save  in  those 
related  to  the  single  cluster  of  delusions  may  coexist.  Years  ago  these 
cases  were  designated  as  monomania,  because  of  the  apparent  lucidity 
of  the  patient  outside  of  the  limited  number  of  fixed  ideas.  Many 
paranoiacs  have  distinguished  themselves  in  sacred  and  profane  history, 
and  even  in  literature.  There  have  been  many  of  these  false  prophets 
who  have  come  to  herald  a  new  religion — Mahomet,  Swedenborg, 
Johanna  Southcott,  John  of  Leyden,  John  Thom  of  Canterbury,  and 
Jeanne  d'Arc.  AVe  have  had  them  even  in  the  United  States  within 
a  few  years — the  healers  exploited  by  the  press.  Among  political  re- 
formers we  had  John  Brown  and  Guiteau.  A  famous  paranoiac  immor- 
talized himself  in  his  autobiography — Benvenuto  Cellini. 

I  have  in  my  possession  a  beautifully  written  manuscript — the 
autobiography  of  a  paranoiac.  He  was  so  dangerously  insane  that  he 
spent  much  of  his  life  in  the  asylum  in  which  he  wrote  this  valua- 
ble work.i  The  volume,  bound  by  himself,  is  entitled  "  The  Piling 
of  Tophet,"  which  is  significant  of  the  sufferings  he  had  undergone  in 
his  unhappy  life.  I  believe  no  better  idea  of  the  typical  form  of  para- 
noia can  be  obtained  than  by  a  careful  reading  of  the  history  of  this 
case  as  given  by  the  person  himself.  It  is  a  graphic  picture  of  the 
steady  evolution  of  the  malady — a  remarkable  self-dissection  of  the 
soul's  anatomy.  Before  presenting  the  extracts  from  his  autobiography, 
I  shall  make  a  few  transcripts  from  his  asylum  history. 

He  was  thirty  years  of  age  at  the  time  of  admission  ;  single  ;  a  farm- 
laborer  by  occupation.  He  was  not  a  church-member,  had  a  common- 
school  education,  and  was  a  native  of  the  United  States.  Hereditary 
predisposition  was  not  acknowledged.  His  mother,  who  accompanied 
him  to  the  hospital,  stated  that  he  had  always  been  delicate  in  his  physi- 
cal constitution,  and  given  to  despondency.  Since  the  age  of  twenty 
he  had  done  little  or  nothing,  because  of  ill  health.  A  year  previous 
to  his  commitment  to  the  hospital  as  a  lunatic  he  shot  himself  in  the 
forehead  in  an  ineffectual  attempt  at  suicide.  Later,  he  developed  de- 
lusions that  the  people  of  the  village  were  acting  upon  him  by  mag- 
netism, spoke  disparagingly  of  him,  and  were  conspirators  against  his 
peace.  During  the  whole  of  his  sojourn  in  the  hospital  he  had  hallu- 
cinations of  hearing,  and  in  the  earlier  period  of  his  stay  had  delusions 
of  persecution.  Toward  the  end  of  his  seven  years  of  hospital  life  he 
gradually  developed,  in  addition,  delusions  of  grandeur.     Although  he 

^  ' '  Extracts  from  the  Autobiography  of  a  Paranoiac, ' '  edited  by  Frederick  Peter- 
son, "Amer.  Jour,  of  Psychology,"  January,  1889. 


PAEAXOIA.  827 

had  occasional  lapses  of  sell-control,  manifested  by  the  breaking  of 
window-glass  or  the  tearing  of  clothing,  he  was  for  the  greater  portion 
of  the  time  sufficiently  self-possessed  to  restrain  whatever  violent  or 
destructive  inclinations  he  may  have  had,  and  was  permitted  to  go  out 
alone  upon  the  large  grounds  of  the  asylum  whenever  he  wished,  and 
to  wander  about  the  woods  at  will. 

It  was  during  the  last  two  years  of  his  stay  at  the  asylum,  while 
still  the  victim  of  constant  auditory  hallucinations,  and  of  mingled 
delusions  of  persecution,  unseen  agency,  and  grandeur,  that  he  Avrote 
the  volume  of  four  hundred  manuscript  pages  with  the  extraordinary 
title  of  "  The  Piling  of  Tophet,"  this  title  being  founded  upon  Isaiah 
XXX,  33.  The  book  itself  is  a  deeper  history  of  his  life  and  mental 
evolution  than  any  but  himself  could  furnish.  It  is  remarkaljle  for  its 
excellent  literary  style  and  for  its  keen  reasoning  and  psychological 
analysis  of  his  own  disordered  mind.  In  it  he  dissects  his  hallucina- 
tions and  delusions  like  a  skilled  anatomist.  It  is  as  fascinating  as  a 
novel.  Every  page  has  its  value  as  an  index  of  the  condition  of  his 
mind  from  childhood  to  the  last  years  of  his  confinement  in  the  asylum  ; 
and  the  story  is  told  with  a  directness  and  simplicity  that  marks  truth 
upon  every  statement  and  lends  it  such  charm  as  pertains  to  all  works 
which  portray  life  with  the  utmost  fidelity.  In  his  preface  and  intro- 
duction he  makes  a  diagnosis  of  his  own  disease. 

Our  author,  as  has  already  been  stated,  was  not  a  church-member, 
and  in  his  book  he  describes  his  early  religious  life  and  his  subsequent 
beliefs  as  they  developed.  His  father  was  a  Universalist  and  his 
mother  a  non-professor  of  religion,  although  she  did  attend  the  Meth- 
odist church.  During  his  boyhood  he  attended  the  Sunday-school 
regularly,  and  at  one  time  the  Episcopal  church ;  but  his  attendance 
upon  divine  service  ceased  in  early  youth.  Both  parents  were  honest, 
conscientious,  and  highly  respected  in  the  community.  They  were  first 
cousins.  The  mother  was  healthy  in  mind  and  body,  but  the  father  is 
reported  to  have  been  exceedingly  eccentric,  possibly  insane.  From 
what  I  subsequently  learned  regarding  him,  he  also  was  sometliing  of  a 
paranoiac.  They  strove  to  bring  up  their  children  carefully  and  to 
educate  them  as  well  as  possible. 

His  father  died  when  the  patient  was  twelve  years  of  age.  Up  to 
the  age  of  thirteen  he  attended  a  country  school  both  winter  and  summer, 
but  after  that  his  farm-work  permitted  him  only  winter  schooling.  Still, 
he  evidently  had  unusual  talents  and  aptitudes,  and  we  find  him  later 
studying  by  himself,  in  the  original,  many  of  the  classic  Latin  authors ; 
and  amoug  his  favorite  companions  were  the  works  of  Boethius,  Lucre- 
tius, Josephus,  a-nd  the  Bible.  His  literary  style  and  modes  of  thought 
are  in  themselves  an  evidence  of  more  than  ordinar}-  attainments  in 
rhetoric,  philosophy,  and  logic. 

The  matter  of  heredity  in  his  case  was  not  sifted  thoroughly  upon 
his  admission  to  the  asylum,  nor  have  I  since  been  able  to  gather  much 
material  relative  to  this  factor  in  his  evolution.  But  one  important 
element  of  this  nature  is  described  in  his  book — an  element  not  only 
hereditary  in  its  character,  l)ut  for  a  long  time  part  of  his  environment, 


828  MENTAL   DISEASES. 

and  undoubtedly  an  influence  modifying  his  mental  condition  both 
before  and  after  his  birth,  I  allude  to  a  great-uncle,  a  brother  of  his 
grandmother  on  his  mother's  side,  who  was  himself  a  paranoiac,  and  who 
lived  upon  the  farm  in  intimate  companionship  with  our  patient  until 
the  latter  was  twenty-three  years  old. 

As  we  read  on  we  see,  from  the  author's  account  of  himself,  how 
heredity  and  environment  gradually  molded  his  physical  and  mental 
characters.  A  shy,  timid,  delicate  child  ;  clever  intellectually  ;  given  to 
oddities  of  speech  and  conduct ;  inclined  to  solitary  musing,  rarely  shar- 
ing the  sports  or  games  of  other  boys — in  him  were  slowly  evolved 
marked  eccentricity  of  demeanor,  a  disposition  to  shun  his  fellows,  a 
misinterpretation  of  their  looks  and  actions  as  regarded  himself,  a  mor- 
bid egotism,  a  consciousness  of  a  gulf  between  himself  and  ordinary 
men,  with  deep  depression,  outbursts  of  passion,  an  inclination  to 
homicide  restrained  but  feebly  by  his  weakened  will,  and  delusions  of 
persecution.  No  doubt  the  derogatory  remarks  he  fancied  expressed 
about  him  in  the  stores  were  the  first  harbingers  of  auditory  hallucina- 
tions. Later,  he  had  murder  in  his  thoughts,  through  the  morbid  hu- 
miliation he  felt  at  the  imaginary  insults  from  others.  J^o  doubt,  as 
his  conduct  grew  more  and  more  strange,  he  did  attract  attention  among 
his  fellow-men,  and  this,  unfortunately,  would  but  feed  the  flame  of  his 
pathological  self-consciousness. 

We  follow  his  history  from  infancy  through  childhood  and  youth  to 
manhood,  and  observe  how,  slowly  but  surely,  the  hereditary  seed  sown 
in  degenerative  soil  took  root  and  flourished.  His  peculiar  auditory 
acuteness,  with  his  morbid  shyness,  soon  gave  rise  to  illusions  of  hear- 
ing, and  these  again  were  transformed  into  hallucinations,  as  is  evident 
if  the  thread  of  the  narrative  is  carefully  followed.  The  curious  foun- 
dation of  his  hallucinations  he  well  illustrates  and  understands.  An 
idea  arises  in  his  own  mind  of  what  people  would  say  in  discussing 
him,  and  immediately  consciousness  in  the  auditory  area  projects  the 
idea  in  spoken  words  into  the  environment.  He  noted  this  peculiarity 
of  his  own  thoughts  being  repeated  to  him  by  the  voices  about  him,  yet 
he  could  not  correct  the  delusions  to  which  they  gave  origin,  but  inter- 
preted the  matter  with  the  reason  and  judgment  of  an  insane  mind. 
He  naturally  had  the  delusion,  founded  upon  his  hallucinations,  that 
people  Avere  j)ersecuting  him,  but  upon  this  now  grew  another  delusion. 
He  began  to  believe  that  they  could  read  and  repeat  his  thoughts  ;  that 
there  was  some  magnetic  means  by  which  his  tormentors  could  draw  oif 
his  thoughts  ;  that  other  wills  could  act  upon  his  body,  dominating  his 
own  will  and  causing  him  to  do  things  he  had  no  desire  or  intention  of 
doing. 

It  was  about  this  time  that  he  was  removed  to  the  asylum.  Several 
chapters  of  his  book  are  devoted  to  a  description  of  his  life  there,  hi& 
religious  beliefs,  illusions,  and  hallucinations.  A  short  time  previous 
to  his  departure  for  the  asylum  he  began  to  read  much  in  the  Bible, 
and,  as  he  says,  noted  passages  which  seemed  to  have  a  special  bearing 
as  regarded  himself.  There  were  several  coincidences  of  this  kind,  and 
he  looked  upon  them  at  first  as   merely  coincidences,  but  in  time  the 


PA  BANG  I  A.  829 

resemblance  became  so  strongly  marked,  to  his  disordered  intelligence, 
that  he  came  to  look  upon  whole  chapters  of  the  Bible  as  referring  to 
himself.  From  this  the  step  was  not  a  great  one  to  the  delusion  of 
being  a  prophet.  In  reading  we  find  that  our  author  had  several  in- 
centives for  writing  this  book.  It  contains  the  autobiography  of  a  new 
prophet,  as  well  as  the  revelation  of  a  new  religion.  From  his  stand- 
point, as  a  man  in  whose  destiny  are  Avrapped  up  the  destinies  of  the 
world,  he  tells  posterity  of  the  tortures  and  trials  he  has  passed  through 
as  an  atonement  for  the  sins  of  the  earth  ;  how  he  was  mocked  and 
scoffed  at,  his  brain  acted  upon  by  magnetic  agency,  and  himself  im- 
prisoned in  a  lunatic  asylum  for  years.  Hence  the  title  of  his  book, 
"  The  Piling  of  Tophet."  But  behind  this  insane  egotism  there  shines 
at  times  some  faint  glimmer  of  the  truth,  so  that  he  frequently  speaks  of 
himself  in  the  terms  used  by  his  fellows,  as  insane,  a  lunatic,  a  mono- 
maniac, as  having  hallucinations  ;  and  he  thinks  the  opinions  of  his 
friends,  relatives,  and  physicians  of  sufficient  worth  to  merit  considerable 
argument  in  his  book.  He  knows  what  insanity  is  ;  he  recognizes  it  in 
his  asylum  associates.  He  could  at  times  "  see  the  man  he  ought  to 
have  become  rising  up  like  a  shadowy  phantom  in  judgment  on  the 
wreck  he  really  was."  But  this  occasional  consciousness  of  their  dis- 
ordered mental  condition  is  by  no  means  infrequent  in  the  insane. 

Shortly  after  writing  his  autobiography  he  was  removed  to  a  county 
asylum,  where  he  remained,  without  change  in  his  mental  condition,  for 
several  years,  when  his  friends  took  him  out  to  live  with  them.  He  died 
a  religious  paranoiac  in  1886.  He  did  not  become  completely  imbecile, 
as  such  cases  often  do  ;  nor  did  he  write  any  further  articles,  so  far  as  I 
am  aware.  Doubtless  the  indifference  with  which  the  world  received 
the  propagandism  of  the  new  prophet  caused  his  philosophical  with- 
drawal from  active  warfare  in  the  fields  of  reform  and  theology. 

In  the  preface  he  defines  the  scope  of  the  book  as  follows  : 

''  This  work  is  given  to  the  public  as  a  lunatic's  defense  of  his  posi- 
tion. Every  effort  I  haA^e  made  hitherto  to  come  to  an  understanding 
with  my  fellow-men,  on  things  which  I  see  to  proceed  from  them,  and 
which  give  my  life  its  whole  shape,  has  drawn  out  nothing  more  than 
blank  denials  of  all  knowledge  of  the  things  I  spoke  of.  Now,  it  is  im- 
possible for  me  to  reduce  my  thoughts  to  the  l^ounds  which  others  have 
been  willing  to  concede.  The  ol^ject  of  this  little  autobiography  is  to 
show  the  form  and  consistency  of  the  thought  that  is  in  my  mind. 

"  I  present  my  evidence  to  the  triljunals  of  last  resort,  the  public  and 
the  press,  and  ask  them  to  try  the  case  and  render  their  verdict.  Have 
I  a  right  to  my  thought,  or  have  I  not  ?  If  not,  where  am  I  deceived  ? 
If  I  have,  why  is^'not  mine  the  true  thought  for  all  men?  " 

A  paragraph  from  the  introduction  further  reveals  the  object  of  his 
confessions  : 

"A  person  is  supposed  to  have  a  reason  for  what  he  does,  and  I 
might  consider  it  incumbent  upon  me  to  tell  the  motives  which  actuate 
me  in  thus  entering  upon  the  work  of  the  scribe  under  circumstances  so 
peculiar.     Is  there  anything  I  have  to  tell  that  might  not  as  well  and 


830  MENTAL  DISEASES. 

more  safely  be  left  untold  ?  It  is  a  question  which  I  do  not  have  to 
consider  and  decide  to-day,  for  I  have  been  long  inspired  with  the  con- 
viction, the  consciousness,  that  I  have  something  to  tell  that  it  would  be 
worth  the  world's  while  to  hear." 

In  another  introductory  paragraph  he  makes  an  excellent  diagnosis 
of  his  mental  infirmity.     Addressing  his  reader,  he  says  : 

' '  I  did  not  tell  you  that  I  am  a  patient  in  an  asylum.  I  am  to  take 
it  for  granted  at  the  outset  that  my  prospective  reader  knows  nothing  of 
my  character,  condition,  or  circumstances  beyond  what  I  tell  him.  I 
am  here  as  an  insane  patient.  I  have  been  here  over  five  years.  .  .  . 
Being  an  insane  man,  it  will  be  nothing  unexpected  that  I  should,  in 
giving  these  reports  of  my  fortunes,  narrate  incidents  and  particulars 
partaking  more  or  less  of  the  marvelous  or  preternatural.  I  am  not 
only  a  lunatic,  but  one  of  the  class  of  lunatics  having  a  controversy  with 
the  world  in  general;  in  other  words,  possessed  with  a  monomania,  or 
crazy  one-sidedly  or  on  a  single  subject." 

In  the  hospital  record  presented  above,  nothing  is  adduced  as  to 
heredity  in  this  case,  and  but  little  stated  concerning  his  mental  condi- 
tion in  early  youth.  These  deficiencies  are,  to  a  great  extent,  supplied 
in  the  autobiography.  I  shall  permit  our  author  first  to  describe  his 
appearance  in  this  world,  in  a  cyanotic  condition,  and  the  characteristics 
of  his  childhood  and  early  youth,  and  subsequently  the  hereditary 
influence  in  his  destiny  : 

"It  is  said  that  I  was  entirely  black  when  I  was  ushered  into  the 
world,  and  that  for  I  forget  how  long  a  period  of  time  I  did  nothing 
but  give  vent  to  heart-saddening  wails.  Was  I  lamenting  the  gift  of 
light,  on  this  morning  of  what  was  to  become  a  woe-burdened  existence  ? 

"  I  was  a  weakly  infant.  I  came  near  dying  of  the  whooping-cough, 
and  it  was  always  asserted,  by  those  who  knew,  that  I  owed  my  life  to 
the  untiring  exertions  of  a  poor  woman  who  lived  a  neighbor,  who 
busied  herself  all  night  with  me,  dipping  me  at  intervals  into  a  tub  of 
warm  water.     My  half-sister  had  it  at  the  same  time  and  died. 

' '  It  will  be  of  use  to  give  an  idea  of  my  nature  and  disposition  in 
my  tender  years.  I  was  ahvays  a  shy,  retiring  child;  not  disposed  to 
make  free  with  strangers;  not  much  given  to  prattle — in  fact,  one  of  the 
sad  and  silent  sort  from  the  first.  I  can  remember  some  peculiar  sensa- 
tions which  used  to  weigh  on  my  mind,  which  go  to  show  that  the 
foundation  of  my  mind-life  was  but  imperfect  from  the  first.  I  used  to 
be  troubled  with  very  strange  feelings  when  I  was  waking  out  of  sleep, 
especially  if  I  had  been  taking  a  nap  in  the  day-time.  It  used  to  seem 
to  me  that  I  was  floating  in  the  air,  and  I  often  thought  to  myself  : 
'  Why,  how  queer  I  have  been  feeling! '  It  was  as  if  I  filled  the  whole 
room,  way  up  to  the  ceiling.  I  Avas  told  by  others  that  I  sometimes 
raised  myself  up  in  bed  after  getting  to  sleep  and  made  an  outcry,  '  Oh, 
don't!  Oh,  don't! '  seeming  to  be  in  great  distress ;  but  the  strange  part 
of  it  is  that  I  could  remember  nothing  about  it.  I  do  not  think  that  I 
ever  remembered  even  their  waking  me,  or  finding  them  at  my  bedside. 
I  only  had  their  Avord  for  it  next  day. 

"As  far  as  I  can  go  back,  I  remember  having  at  times,  but  not  fre- 


PARANOIA.  831 

quently,  impressions  which  must  be  identical  with  what  I  have  lately 
heard  others  speak  of  as  '  double  memory. '  The  feeling  would  all  at 
once  creep  over  me  that  the  very  thing  I  was  present  with,  my  ideas  and 
perceptions  at  that  time,  had  happened  to  me  once  before  in  just  the 
same  sequence  and  arrangement.  I  have  heard  this  explained  as  due 
to  a  lack  of  simultaneity  in  the  action  of  the  two  lobes  of  the  brain,  the 
tardy  one  remembering  what  had  already  passed  through  the  other. 
My  own  theory  was  different,  leaving  the  organ  acting  out  of  con- 
sideration. I  only  went  so  far  as  to  look  at  it  as  a  mistaken  quahty 
in  the  perception — an  erroneous  attaching  of  the  nature  of  the  act  of 
remembering  to  what  was  really  the  act  of  thinking  in  the  present. 

' '  I  was  very  early  in  life  an  observer  of  my  own  mental  peculiarities, 
to  a  degree  which  I  think  must  be  a  very  rare  exception.  I  often  used 
to  be  sensible  of  an  unsatisfactoriness  in  my  consciousness  of  what  sur- 
rounded me.  I  used  to  ask  myself,  '  Why  is  it  that  while  I  see  and 
hear  and  feel  everything  perfectly,  it  nevertheless  does  not  seem  real  to 
me  ?  It  is  as  if  I  were  in  danger  of  forgetting  myself  and  the  place 
where  I  am! '  I  often  wondered  even  how  I  kept  the  run  of  things  as 
well  as  I  did.  I  always  found  myself  holding  on  to  the  orderly  and 
proper  connection  of  my  acts,  and  yet  from  my  feelings  I  could  not  have 
answered  for  my  doing  so.  I  can  remember  sitting  at  my  desk  in 
school,  when  a  small  boy,  and  dwelling  with  melancholy  on  this  dim- 
ness in  my  perception  of  existence,  and  wondering  how  it  was  with 
others  in  this  respect.  I  wondered  to  myself  if  life,  as  ordinarily  be- 
stowed, included  this  deficiency. 

"  I  showed  in  my  tastes  and  behavior  a  harmony  with  the  internal 
composition  of  my  mind.  I  was  never  given  to  the  active  sports  which 
the  common  run  of  boys  take  so  much  delight  in. 

' '  The  simple  fact  is  that  I  had  a  languid  nervous  development,  and 
from  the  necessity  of  my  organization  could  not  have  much  capacity  or 
relish  for  sports  of  agility. 

"  If  I  could  compound  a  boy  of  my  own  I  should  try  to  improve  on 
the  model  I  remember  to  have  exhibited  in  myself. 

"  It  is  not  true  that  I  was  regarded  or  treated  as  strange  or  deficient 
in  my  wits.  Such  an  idea  would  look  misplaced  to  those  who  knew 
me  and  consorted  with  me  in  those  days.  These  differences  are  perhaps 
more  evident  to  myself  than  they  ever  were  to  the  greater  part  of  my 
acquaintances.  I  brooded  on  this  side  of  my  character  at  a  later  period, 
and  I  no  doubt  remain  liable  to  give  greater  prominence  to  disparaging 
traits  than  some  impartial  observers  would  justify  me  in  doing. 

"  As  a  general  rule,  my  harmless  and  peaceable  disposition  kept  me 
out  of  squabbles  with  my  schoolmates.  If  I  was  approached  in  an 
aggressive  way,  I  met  it  wdth  absolute  non-resistance,  which  in  my  case 
had  the  disarming  effect  which  is  attributed  to  it  by  pious  moralists. 

"If  we  change  the  scene  from  the  playground  to  the  schoolroom,  we 
shall  find  that  I  attained  a  distinction  of  my  own,  apart  from  the 
average,  and  more  to  my  advantage  there.  I  was  always  a  favorite  with 
my  teachers.  I  never  gave  them  any  trouble,  and  took  to  my  studies 
with  a  willing  relish  that  could  not  but  be  pleasing  to  them.  I  learned 
to  read  before  I  went  to  school;  in  fact,  like  an  old  asylum  acquaint- 
ance, Mr.  M. ,  inventor  and  infidel  monomaniac,  I  can  almost  say  that 
I  can't  remember  when  I  could  not  read. 

"I  was  frequently  singled  out  for  complimentary  remarks   on  my 


832  MENTAL  DISEASES. 

proficiency  in  my  studies.  I  gave  evidence  of  some  talents  of  a  higher 
kind — could  draw,  for  instance,  better  than  any  boy  in  the  school. 

"One  of  the  most  marked  weaknesses  of  my  character,  as  a  child, 
was  my  susceptibility  to  being  teased. 

' '  After  having  pondered  some  on  the  traits  of  the  human  animal  in 
this  particular,  I  have  come  to  the  conclusion  that  there  is  no  further 
explanation  needed  than  that  the  impression  made  on  the  teaser  by  the 
teasable  is  such  as  to  naturally  prompt  the  acts  constituting  the  teasing, 
as  the  sense  of  burning  makes  us  shrink,  and  an  aroma  suggestive  of  a 
fine  flavor  tempts  us  to  bite.  I  feel  convinced  that  the  liability  to  be 
teased  rests  on  a  principle  that  has  a  mighty  influence  in  the  motions  of 
the  soul  of  humanity. 

"My  misdeeds,  as  a  child,  were  rarely  prompted  by  a  love  of 
mischief  or  the  result  of  headlong  thoughtlessness. 

' '  I  had  a  well-defined  idea  of  the  nature  of  sin,  and  I  used  fre- 
quently at  night  to  recall  the  events  of  the  day,  and  reflect  on  instances 
in  which  I  had  transgressed  and  given  way  to  ill-humor,  and  form  reso- 
lutions to  try  and  do  better.  From  some  of  the  most  flagrant  of  the 
sins  and  improprieties  to  which  small  and  larger  boys  are  prone  I  was 
entirely  free. 

"  My  early  training  can  not  be  said  to  have  been  a  predominantly 
religious  one.  My  mind  was  neither  imbued  with  ineradicable  preju- 
dices nor  prepared  for  reaction  to  the  other  extreme  by  excessively  rigid 
sectarian  drilling  and  formalism. 

"I  worked  steadily  upon  the  farm,  though  with  moderation,  at 
such  kinds  of  work  as  I  seemed  to  be  equal  to.  The  heavier  kinds  of 
w^ork,  such  as  plowing  and  wagoning,  as  also  the  marketing  of  the 
produce,  were  attended  to  by  my  great-uncle. 

"It  is  a  somewhat  delicate  subject  to  manage  to  my  satisfaction 
this  that  I  am  about  to  enter  upon,  but  it  demands  candid  and  impar- 
tial treatment,  because  the  events  that  followed  in  later  years  can  not 
be  rightly  understood  without  it.  It  is  impossible  for  me  to  give  a 
veracious  sketch  of  my  soul-life  during  this  period  without  dwelling 
quite  minutely  on  the  characteristics  of  my  great-uncle.  He  was  a  man 
who  had  roughed  it  a  good  deal  in  the  world,  had  been  at  one  time  in 
his  life  a  live-oaker  in  Florida.  How  his  temper  and  disposition  may 
have  been  at  an  earlier  period  I  can  not  say — I  only  remember  him  as 
a  man  possessed  of  the  belief  that  a  certain  young  man  living  on  an 
adjoining  farm  had  the  power  to  torture  him  at  his  pleasure,  both  by 
bothering  his  brains  ancl  inflicting  physical  pain;  which  power  he  made 
use  of  to  such  good  effect  that  the  poor  victim  was  almost  constantly 
kept  busy  holding  him  at  bay  by  means  of  cursings  of  the  most  fierce 
and  vigorous  description.  While  at  work  with  the  horses  in  the  fields, 
and  when  driving,  he  would  intermix  his  commands  to  the  animals 
with  savage  execrations  of  the  troubler  of  his  peace.  The  unfortunate 
man  was  troubled,  at  certain  seasons  of  the  year  especially,  with  sore 
feet,  and  at  such  times  his  imprecations  against  the  offender  would 
fairly  rise  to  yells,  and  were  almost  blood-curdling  in  their  intense 
ferocity.  Thus  it  went  on  day  and  night.  He  slept  in  a  small  room  in 
one  of  the  outbuildings,  and  often  he  could  be  heard  at  a  great  distance 
off  shouting  out  threats,  sometimes  throwing  boots  or  boot-jacks  against 
the  boarded  side  of  the  building  where  he  lodged  to  put  in  the  inter- 
jection points. 


PARANOIA.  833 

"  It  may  be  imagined  that  a  boy  of  a  reserved  and  sensitive  disjDOsi- 
tion,  as  I  was,  could  not  assimilate  very  well  with  such  a  character  as 
this.  I  was  always  distant  in  my  intercourse  with  him,  and  a  feeling 
of  aversion  for  his  habits  of  savagery  led  me  to  avoid  coming  in  contact 
with  him  more  than  Avas  rendered  necessary  by  our  joint  labors  on  the 
farm. 

"As  the  years  passed  on  and  I  continued  to  live  in  the  presence 
of  my  uncle's  fierce  demonstrations  of  hostility  against  the  invisible 
destroyer  of  his  comfort,  my  tolerance  for  his  conduct  insensibly  gave 
way.  I  had  now  reached  the  age  of  eighteen  or  nineteen;  was  a  tall, 
slender  youth,  not  strong  either  in  nerve  or  muscle. 

"The  exhibition  of  his  ruling  passion  called  up  more  and  more 
determined  feelings  of  antagonism  in  my  breast. 

"Before  I  knew  it  I  had  gone  a  criminal  length  in  my  resentful 
feeling.  I  came  at  last  to  feel  that  a  person  of  such  a  thoroughly 
savage  character  did  not  deserve  more  indulgence  than  a  mad  dog.  My 
position  from  that  time  was  one  of  contingent  murder.  Alas  !  that  I 
should  have  been  content  to  let  such  a  state  of  things  last  a  single  day. 
The  frightful  danger  of  my  situation  ought  to  have  been  sufficient  to 
spur  me  to  sacrifice  everything  to  escape  from  it.  But  I  was  in  chains, 
the  chains  of  apathy,  impotence,  and  incapacity,  and  I  could  only  stay 
where  I  was  and  fume  against  the  object  of  my  detestation. 

' '  I  must  always  regard  it  as  one  of  the  most  unfortunate  things  in 
my  unfortunate  career  that  I  should  have  been  placed  in  contact  with 
this  much  to  be  commiserated  sufferer  at  such  a  time  of  life.  It  was 
not  the  man  himself  that  I  hated.  When  my  judgment  could  act  with- 
out impediment,  I  saw  that  his  unpleasant  behavior  was  entirely  the 
phenomena  presented  by  his  never-ending  war  against  what  was,  in  his 
eyes,  the  most  wicked  and  cruel  of  persecutions.  I  could  then  pity  him 
and  dismiss  all  rancorous  thoughts." 

This  antipathy  led  to  a  change  in  the  residence  of  our  author.  He 
felt  that  he  must  be  separated  from  his  uncle,  and,  accordingly,  he  re- 
moved to  a  town  at  some  distance  from  the  farm.  It  is  curious  that 
he  never  speaks  of  his  uncle  as  insane,  and  it  is  probable  that  both  his 
mother  and  himself  and  other  relatives  regarded  his  persecutory  delu- 
sions as  merely  evidence  of  eccentricity.  Soon  after  removing  to  town 
he  had  some  pulmonary  difficulty,  and  he  speaks  at  some  length  of  this 
as  follows  : 

"  In  the  depressed  state  of  my  nerves  I  imagined  myself  much  worse 
than  I  really  was,  and,  like  many  others  in  the  same  condition,  I  felt 
as  if  I  was  liable  to  sink  away  and  die  at  any  time.  My  disease  was 
accompanied  with  periodical  accesses  of  fever,  and  in  the  fictitious 
strength  of  excitelnent  given  by  this  my  mind  seemed  to  gain  an  ab- 
normal activity.  It  was  at  this  time  that  I  first  received  a  revelation  on 
the  mysteries  of  the  human  soul  that  had  an  all-dominant  effect  on 
my  destinies  and  the  turn  of  my  thoughts  ever  after.  ...  I  now 
learned  what  had  always  been  to  me  a  hidden  myster}^ — what  Avas  the 
meaning  of  strength  of  Avill  and  strength  of  intellect.  Before,  I  had  CA^er 
lived  enshrouded  in  mists  and  clouds.  In  that  transitory  strength  giA^en 
by  the  fever  coursing  through  my  veins,  I  now  saAV  the  man  I  ought 
to  haA'e  become  rising  up  like  a  shadoAvy  phantom  in  judgment  on  the 
53 


834  MENTAL   DISEASES. 

wreck  which  I  really  was  .  .  .  My  agitation  was  so  great  that  my 
mother  and  the  neighbors  seemed  to  fear  that  I  was  going  crazy.  / 
felt  that  I  had  been  crazy  for  a  long  while  and  had  just  recovered  reason. 
It  was  a  fact.  But  I  was  constrained  to  lock  up  my  remorseful  agony 
in  my  own  breast. ' ' 

We  haye  seen  that  our  patient  was  throughout  his  early  youth 
morbidly  subjectiye,  and  his  hypochondriasis  increased  with  years.  He 
had  now  attained  the  age  of  twenty-three  ;  we  shall  let  him  describe  his 
mental  condition  and  habits  of  hfe  at  this  time.  In  this  description  we 
shall  see  the  gradual  growth  of  persecutory  ideas  upon  a  favorable  soil : 

"My  strength  and  endurance  were  not  sufficient  for  manual  labor, 
and  I  did  not  feel  confidence  enough  in  the  clearness  and  energy  of  my 
mind  to  justify  me  in  making  apjolication  for  any  ]30st  where  head-work 
w^ould  have  been  demanded,  or  for  which  ready  presence  of  mind  or  a 
good  address  would  haye  been  required.  But  it  was  the  unpleasantness 
felt  on  contact  with  my  fellow-men  that  operated  more  strongly  than 
anything  else  in  binding  me  down  to  the  course  of  life  to  which  I  de- 
voted myself.     I  felt  my  deficiencies  most  keenly  every  time  I  met  a 

human  being  face  to  face I  could  not  do  otherwise  than 

shun  what  was  so  galling  to  my  sensibility,  while  appearing  to  conduce 

to  no  desirable  end But  I  am  going  to  show  that  I  still 

remained  exposed  to  very  great  dangers,  and  it  is  as  true  as  it  was 
before  that  I  shunned  the  only  means  of  averting  the  calamities  threat- 
ening me,  no  doubt  of  necessity  at  this  stage,  and  in  obedience  to  the 
eternal  decree  that  every  tree  shall  spread  out  and  develop  in  accord- 
ance with  the  qualities  given  to  it  '  before  it  was  in  the  ground. '  I  did 
not  like  the  constraint  imposed  upon  me  by  the  presence  of  man.  I  did 
like  the  freedom  of  solitude.  I  strongly  disliked  many  things  I  noticed 
in  the  manner  and  Avords  of  some  I  met,  and  there  was  nothing  to  pre- 
vent this  dislike  from  occasionally  being  absorbed  into  my  solitary 
musings,  to  find  its  final  resolution  in  the  passion  of  indignation  in  its 
various  degrees  of  intensity  as  the  case  might  be.  I  have  spoken  before 
of  my  defective  means  of  defense  against  '  teasing '  or  mocking  for  the 
purjDOse  of  troubling.  I  was  always  terribly  alert  and  sensitive  to  all 
kinds  of  '  snubs '  and  sneers,  and  oblique  remarks  in  general,  on  their 

proficiency  in  which  some  people  pride  themselves  so  much 

I  was  also  disagreeably  impressed  by  the  wa3'S  of  some  who  showed  a 
disposition  to  turn  their  attention  to  myself,  instead  of  confining  them- 
selves to  the  subject  I  Avas  presenting  to  them. 

' '  I  Avas  being  carried  into  a  state  of  secret  enmity  to  mankind  in 
general  by  the  j^reA'ailing  tenor  of  my  brooding  meditations,  and  there 
was  no  correctiA^e  present. 

' '  But  all  receiA^ed  a  hue  from  a  yearning  for  what  was  worthy 
in  life,  paired  with  a  mournful  sense  of  its  hopeless  absence.  AVhat- 
ever  AArrong  turns  I  may  in  my  weakness  have  been  betrayed  into,  it  is 
impossible  that  I  should  look  upon  ni}^  then  existing  frame  of  mind 
as  a  Avhole  with  repentant  feelings.  As  well  condemn  righteousness- 
and  holiness  itself  ! 

' '  "When  I  admit  that  I  occasionally  was  OA^ercome  Avith  an  irruption 
of  hard  feelings  toAvard  wrong-doing  man,  it  will,  of  course,  not  be- 
understood   that   I   was   habitually   morose    and    spiteful    in   temper. 


PARANOIA.  835 

Nothing  could  be  further  from  the  truth.  What  commotion  there  was 
was  mostly  internal,  rarely  reaching  the  surface  in  visible  ebullitions. 
.  I  occupied  myself  with  the  trifling  labors  of  my  garden, 
dwelling  with  interest  and  pleasure  on  the  progress  of  my  crops  and 
flowers,  and  every  now  and  then  took  a  ramble  over  to  the  woods  lying 
to  the  south,  which  were  a  favorite  place  of  resort  to  me  all  the  while  I 
lived  there.  There  I  botanized  and  moralized,  explored  the  recesses  of 
the  woods,  enjoyed  the  calm  quiet  of  nature,  and  groaned  over  my 
hapless  condition,  wondering  what  it  was  to  come  to. 

"There  were  some  little  things  that  happened  to  me  the  first  year 
after  I  left  the  farm  which  became,  as  it  were,  a  kind  of  sample  of  what 
I  must  continue  to  expect,  and  the  memory  of  which  had  more  influ- 
ence  over   my  action  in  after  time  than   I  was  aware  of   myself,   no 

doubt When  I  was  around  the  city,  thinking  I  might  get 

employment  I  called  on  one  of  my  old  acquaintances,  who  was  then  in 
a  store.  I  talked  with  him  a  few  minutes  at  that  time.  I  called  again 
a  short  time  after,  when  I  was  told  by  the  proprietor  that  the  gentle- 
man I  had  called  to  see  was  not  in.  There  were  a  number  of  men 
present  in  the  store, — salesmen, — and  it  became  apparent  to  me  that  they 
were  trying  to  exhibit  an  offensive  demeanor  toward  me,  or  perhaps  it 
would  be  as  true  to  say  that  they  were  moved  to  make  a  derisive  de- 
monstration against  me.  At  all  events,  all,  with  perhaps  the  excep- 
tion of  the  proprietor,   stood  with  contortions  of   countenance,  which 

was  perhaps  laughter,  until  I  retired I  found  it  hard  to 

consign  this  to  forgetfulness.  At  first  it  lay  dormant,  but  it  would 
come  up,  and  I  must  confess  I  had  hard  feelings,  even  revengeful  feel- 
ings, toward  the  actors.  Another  thing  happened  the  same  fall.  I 
went  to  a  store,  and,  standing  at  the  counter,  was  noticed  by  one  of  the 
clerks, — an  Irishman, — who  came  to  me  and  said,  '  I  always  wait  on  the 
little  boys  first,'  and,  as  I  took  no  notice  of  the  remark,  seemed  so  de- 
termined his  words  should  not  be  lost  on  me  that  he  repeated  them, 
with  the  addition,  'like  you.'  As  before,  it  produced  no  immediate 
effect,  but  it  afterward  rose  and  rankled  in  my  memory,  and  I  was  not 
able  to  keep  clear  of  imagining  vindictive  things.  In  fact,  to  tell  the 
truth,  in  both  cases  I  felt  that  blood  would  have  been  sweet  to  me. 
My  mode  of  thinking  on  these  incidents  no  doubt  had  in  it 

much  of  the  character  of  insanity The  effect  was  that  I 

got  settled  down  into  the  fixed  idea  that  contact  with  the  thoughtless, 
evil  world,  in  my  state  of  body  and  mind^  would  impose  upon  me  the 

necessity  of  committing  crime  in  vindication  of  my  honor 

I  let  these  bloody  memories  tinge  my  whole  mind,  and  all  its  anticipa- 
tions and  resolutions  for  the  future 'I  see,'  I  said  to  my- 
self, in  substance,  '  that  these  galling  collisions  are  the  natural  penalties 
of  being  imperfect. ' 

"It  may  be  ^as  well,  for  the  prevention  of  misconceptions,  to  say 
that  I  never  took  one  step  toward  putting  any  design  thence  arising 
into  execution.  I  had  no  designs.  I  never  armed  myself,  or,  in  fact, 
went  any  further  than  to  rehearse  the  drama  of  revenge  in  my  own 
mind.  The  pistol  I  bought  was  one  which  I  Avould  not  have  trusted  for 
a  moment  to  carry  for  the  purpose  of  self-defense Never- 
theless, the  events  on  the  farm  show  that  my  wickedness  was  not 
altogether  of  a  mimic  kind,  and  I  will  not  attempt  to  escape  righteous 
judgment. 


8:36  MENTAL   DISEASES. 

"I  used  to  make  many  resolutions  about  regularity  in  habits  of  eat-" 
lug,  which  I  found  myself  powerless  to  keep.  A  sense  of  depression 
and  vacuity  would  come  over  me,  aggravated  by  my  solitary,,  monoto- 
nous life,  I  presume,  and  often  by  an  obstructed  state  of  the  alimentary 

organs It  is  a  common  feature  in  insanity  or  semi-insanity 

left  to  itself,  I  think.  I  also  exerted  my  brain  to  the  extent  of  abuse, 
I  know,  in  the  way  of  study.     ...  I  used  to  study  Latin  for  a 

pastime,  and  often  kept  cudgeling  my  brains  over  Cicero  and  Csesar 
until  the  top  of  my  head  was  very  sore.  This  solitary  immersing  of 
an  enfeeblecl  mind  in  study,  with  obliviousness  to  myself  and  all  sur- 
roundings, Avas,  no  doubt,  a  help  toward  the  grand  consummation  that 

took  place  in  the  fullness  of  things I  suffered  a  good  deal 

from  bodily  ailments.  My  liver  seemed  to  be  thoroughly  out  of  order 
and  torj)id.  I  had  a  feeling  of  hardness  and  inflammation  in  my  sides 
regularly,  a  certain  length  of  time  after  meals  ;  digestion  was  bad, 
appetite  irregular — in  fact,  every  sign  of  a  deadlock  in  the  vital  func- 
tions. ' ' 

His  mother  and  he  removed  to  another  village  in  1871,  when  he 
was  twenty-eight  years  of  age,  by  which  time  there  was  but  little 
question  of  his  insanity,  even  among  his  relatives.  I  let  him  take  the 
thread  of  the  story  again  at  this  epoch  : 

"  When  my  mother  was  making  preparations  for  moving  she  asked 
me  to  help  in  packing  up  some  chairs.  I  made  an  effort  to  apply  my- 
self to  the  task,  but  suddenly  found  myself  overcome  by  my  feelings, 
and  before  I  knew  what  I  was  about  I  had  shivered  one  of  the  chairs  to 
fragments.  A  most  unpromising  omen  !  The  fact  is  that  I  was,  and 
had  been  for  some  time,  in  a  state  which  any  physician,  knowing  the 
facts,  would  have  pronounced  to  be  unmistakable  insanity.  But  I 
had  diiferent  ideas  about  what  constituted  insanity,  and  often  thought 
to  myself  that  if  I  did  get  put  into  an  asylum,  as  had  been  threatened, 
they  would  not  keep  me,  because  they  would  see  that  I  was  perfectly 
rational.     I  have  learned  more  about  the  subject  since. 

' '  Things  of  the  kind  I  have  told  of  had  happened  to  me  before,  at 
uncertain  intervals,  during  several  years,  an  obstructed  state  of  the 
bowels  bringing  on  a  turn.  I  would  get  into  such  a  condition  of  exag- 
gerated discomfort  as  to  lose  for  a  moment,  or  sometimes  quite  a  spell, 
my  control  over  my  actions,  and  act  very  strangely.  Sometimes  I 
dashed  down  an  article  I  happened  to  have  in  my  hands,  or  demolished 
the  first  thing  that  came  to  hand;  sometimes  I  gave  vent  to  my  feelings 
by  grating  my  teeth,  '  clawing  '  my  face,  and  going  through  strange 
grimaces  and  agonizing  contortions.  My  face  seemed  to  me  to  be  par- 
alyzed when  I  had  such  turns,  as  if  lifeless.  The  worst  thing  I  ever 
did  was  when  I  flew  at  my  mother  in  a  sudden  access  of  frenzy  one  day, 
when  she  had  wrought  upon  my  feelings  by  talking  to  me  irritatingly, 
and  l^it  out  a  mouthful  of  her  hair.  .  .  .  When  I  was  committed 
to  the  asylum,  at  a  later  day,  it  was  reported  as  one  of  my  symptoms 
that  I  had  delusions  about  my  mother  being  my  enemy,  etc. ,  but  noth- 
ing could  be  further  from  the  truth.  ...  I  often  grieved  in  secret 
over  my  inability  to  be  a  stay  and  protection  to  her,  bereft  as  she  was 
of  all  other  support,  but  all  in  vain. 

' '  In  my  new  home  I  was  in  one  of  a  row  of  houses,  with  strangers 


PABAXOIA.  837 

living  near  on  both  sides,  and  the  sense  of  the  presence  of  the  evil 
which  I  had  shrunk  from  so  long  weighed  down  upon  nie  with  crushing 
weight.  After  a  while  my  spell  of  hyj^ochondriacal  despondency 
passed  off,  and  I  settled  down  into  the  way  of  living  which  I  adhered 
to  as  long  as  I  remained  there.  As  to  getting  acquainted  with  my 
neighbors,  or  having  any  intercourse  or  dealings  with  them,  that  was 
altogether  out  of  the  question.  ...  I  now  had  more  of  the  feeling 
of  constraint,  from  the  knowledge  that  I  was  moving  under  the  eyes  of 
people  who  were  strangers  to  me,  than  the  strangest  of  the  strange 
could  be  to  a  person  of  the  ordinary  stamp.  Sometimes  I  heard  re- 
marks which  did  not  affect  my  feelings  flatteringly,  but  that  was  not 
common. 

'  'Along  in  June  I  had  a  worse  spell  than  common  of  the  kind  of 
nervous  stagnation  or  will-impotence  of  which  I  have  spoken,  and  per- 
petrated some  quite  irregular  acts  before  my  fetters  became  slackened. 
In  my  despair  I  tore  the  collar  from  my  shirt,  tore  the  slippers  I  was 
wearing,  dashed  ni}'  fist  into  a  tempting  dish  which  my  mother  was 
offering  me  to  eat,  and  other  things  of  the  kind.  The  house  we  occu- 
pied was  owned  by  a  maiden  lady  who  lived  with  her  sister  in  part  of 
the  house.  ...  In  the  evening,  after  the  other  sister  returned, 
who  had  been  absent  during  the  day,  I  overheard  a  few  words  which 
showed  ])lainly  enough  that  the  events  of  the  day  were  being  discussed 
in  no  very  gratified  humor.  It  was  evident  that  my  acts  were  severely 
reprobated." 

The  next  day  the  justice  of  the  peace  called  upon  him  and  admonished 
him  to  restrain  himself,  hinting  of  the  asylum.  Of  this  our  author 
says  : 

"The  dragon's  tooth  of  reprimand  that  had  been  left  in  my  mind 
grew  into  a  monster,  in  whose  presence  I  found  it  impossible  to  live, 
and  I  had  a  fresh  access  of  despair.  It  was  a  hot  June  morning.  I  re- 
member seizing  a  razor  and  flourishing  it,  and  saying,  '  Show  me  that 
rascal  and  I  will  slaughter  him,'  or  words  to  that  effect,  meaning,  of 
course,  the  justice  of  the  peace." 

Both  homicidal  and  suicidal  inclinations  had  long  been  haunting  the 
secret  corners  of  his  mind,  for  three  years  before  he  tells  of  buying  a 
pistol  for  the  express  purpose  of  making  way  with  himself  or  some  one 
else.  On  this  day,  after  meeting  the  officer,  he  determined  upon  suicide. 
He  w^alked  out  to  two  different  country  stores  and  bought  ammunition. 
On  his  way  back  he  passed  some  men  in  a  field.  They  all  looked  at 
him,  and  one  of  them  "  laughed  loud  and  mockingly,  and  then  cried  out, 
in  a  sort  of  squealing  way,  the  intention  of  which  could  not  be  mis- 
taken." Then  he  played  a  game  of  croquet  with  a  young  man  at  his 
uncle's,  and  oyerheard  the  young  man  make  a  covert  and  derisive  re- 
mark.    He  continues  : 

"  I  passed  the  next  day  in  brooding,  silent  melancholy.  It  was  a 
rainy  day  and  in  accord  with  my  feelings.  .  .  .  That  night  I 
wrote  a  little  statement  to  be  left  behind.  ...  It  can  not  be  said 
that  I  plunged  thoughtlessly  into  the  gulf  of  self-murder.  I  had  from 
the  first  gaged  the  responsibility  I  was  taking  on  myself,   as  fully  as 


838  MENTAL   DISEASES. 

my  mind  was  capable  of  doing  it.  I  felt  the  whole  weight  of  the  con- 
demnation that  rested  upon  me  for  committing  such  a  deed. 
I  passed  some  part  of  the  hours  of  the  night  in  sleep.  In  the  morning 
my  mother  came  to  the  door  to  see  how  I  was,  and  I  grasped  her  hand 
with  a  gesture  of  agonized  despair.  She  took  it  as  an  indication  that  I 
was  going  to  have  one  of  my  wild  spells  again,  and,  as  she  told  me 
afterward,  began  to  anticipate  some  work  of  demolition  after  I  should 
come  down-stairs.  After  she  had  gone  down,  I  went  and  took  the  pistol 
from  the  stand-drawer,  put  on  a  fresh  cap,  got  into  bed  again  and 
propped  up  my  head  on  the  pillows,  placed  the  muzzle  of  the  pistol 
against  the  center  of  my  forehead,  and  fired." 

He  lost  considerable  blood  from  the  scalp-wound,  but  the  bullet  had 
glanced  off;  and,  although  he  now  tried  to  starve  himself,  he  was  up 
and  about  in  a  few  days  as  usual,  attending  to  his  garden  with  bandaged 
forehead.     He  continues  : 

' '  There  were  some  steps  taken  toward  getting  me  into  an  asylum 
after  my  abortive  attempt  at  suicide,  but  as  there  were  difficulties  about 
it,  and  I  appeared  perfectly  sensible  and  rational,  my  relatives  concluded 
to  let  it  rest. 

' '  From  the  time  of  my  shooting  until  the  next  spring  there  was  not 
much  that  deserves  mention.  How  were  my  thoughts  about  suicide  ? 
It  must  be  said  that  I  had  not  totally  renounced  that  idea. 
I  used  very  often  to  scan  the  beams  in  the  wood-house  and  the  coils  of 
clothes-line  in  the  garret.  .  .  .  The  old  difficulty  of  giving  way 
under  the  slighting  or  displeasing  demonstrations  from  others  remained 
as  bad  as  ever.  I  remember  once  I  was  so  wrought  upon  by  some 
trifling  thing  said  or  done  by  one  of  my  relations  that  I  kicked  out  the 
bottom  of  a  cane-seat  chair  I  was  resting  my  feet  on,  in  a  sudden  par- 
oxysm of  impotent  emotion." 

About  this  time  he  also  made  a  futile  attempt  to  poison  himself  by 
drinking  a  bottle  of  strong  tincture  of  valerian  that  he  had  made 
himself.     That  incident  he  describes,  and  then  proceeds  : 

' '  It  was  my  intention,  when  I  began  this  sketch  of  my  life,  to  give 
greatest  prominence  to  that  part  beginning  with  my  troubles  in  Clinton 
Street — that  is  to  say,  the  period  of  confirmed  lunacy  with  hallucinations, 
according  to  the  world's  avowed  decision;  but  it  appears  at  present  that 
my  project  is  not  to  go  into  fulfilment.  I  have  been  greatly  delayed  in 
doing  as  much  as  I  have  by  lack  of  strength. 

' '  To  make  the  account  which  I  have  given  as  full  an  exhibition  of 
my  condition  at  the  time  my  hallucinations,  if  such,  appeared,  I  will 
note  some  further  defects  in  my  mental  action  which  I  had  noticed  up 
to  this  time.  First,  two  or  three  things  indicating  original  lack  of 
control  over  the  brain  by  the  will,  or  non-identification  of  my  will  with 
the  action  of  my  brain,  and  which  I  must  count  for  predisposition. 
I  have  been  troubled  from  my  boyhood  with  a  tendency  of  my  brain  to 
see  things  it  ought  not  to  see  in  what  is  placed  before  my  eyes.  This 
refractoriness  does  not  extend  to  all  kinds  of  monstrous  visions,  but  is 
limited  to  the  singling  out  of  the  lineaments  of  the  human  face  in  the 
outlines  of  objects  seen.     The  annoyance  I  have  experienced  from  this 


PARANOIA.  839 

has  varied  greatly,  according  to  the  state  of  my  health.  When  I  used 
to  be  sick  with  the  fever  and  ague,  I  would  lie  in  bed  and  gaze  at  the 
coarsely  daubed  window-shades  in  my  bedroom,  until  I  had  made  out 
every  possible  kind  of  a  profile  that  could  be  distinguished. 

' '  The  other  of  the  two  most  serious  abnormal  peculiarities  is  the 
supplying  of  missing  articulations  to  vocal  sounds,  heard  but  not 
understood  distinctly,  so  as  to  give  my  mind  the  impression  of  certain 
words,  at  the  same  time  that  I  knew  I  had  not  understood.  Sometimes 
I  have  been  really  cheated  this  way,  and  only  found  it  out  by  inquiring 
afterward.  This  might  not  give  conclusive  proof  of  the  deception,  it  is 
true.  Not  to  violate  privacies,  I  will  illustrate  supposititiously.  If 
it  were  proclaimed  aloud,  far  enough  from  me  to  allow  the  inflections 
but  not  the  articulations  to  reach  my  ear  with  certainty — 

We  See  Where  Lies  the  Dreadful  Secret  ! 

my  mind  might  involuntarily  and  instantaneously  reshape  it  in  such  a 
way  that  I  would  understand  : 

Deceive  Where  Lies  Were  Ever  Sacred  ! 

' '  My  attention  was  always  quite  easily  disturbed  by  noises,  par- 
ticularly talking.  In  boyhood  the  sound  of  voices  in  conversation  at  a 
little  distance  after  I  had  retired  to  rest  often  gave  me  very  serious 
annoyance,  showing  excessive  irritability  of  the  brain. 

' '  Such  was  my  mental  state  on  the  eve  of  my  being  overtaken  by  a 
more  marvelously  awful  fate  than  ever  fell  to  the  lot  of  mortal  man. 

' '  My  original  purpose  was  to  follow  the  incidents  having  a  bearing 
on  my  mental  fortunes  with  tolerable  minuteness,  in  an  unbroken  chain, 
up  to  the  time  of  reaching  that  wonderful  state  in  which  I  have  existed 
for  the  last  six  and  one-half  years. 

"  I  shall  be  obliged  to  confine  myself  more  to  generalities. 

' '  I  was  in  such  a  towering  state  of  morbid  sensitiveness  that  a  slight 
tinge  of  impertinence,  brusqueness,  or  fancied  contemptuousness  in  the 
manner  of  those  I  met,  put  me  on  the  rack  at  once.  ...  It  began 
to  occur  to  me  after  a  little  that  my  ears  were  becoming  wonderfully 
acute  for  such  things.  Very  often  I  would  hear  lively  discussions  on 
my  character,  and  disputes  about  the  proper  epithets  and  titles  to  be 
applied  to  me,  which  I  understood  perfectly  at  an  astonishing  distance 
off.  ...  I  was  wrought  up  to  such  a  pitch  that  I  formed  a  resolve 
that  if  I  were  given  a  sufficiently  open  provocation,  I  would  attempt  a 
bloody  revenge,  and  on  one  occasion  went  out  with  a  razor  in  my 
pocket.  ...  I  had  an  oppressive  feeling  of  impotence,  as  if  para- 
lyzed, and  suddenly  did  things  I  had  no  intention  of  doing,  as  in 
breaking  glass.  .^  .  .  I  had  a  soreness  all  through  my  limbs  which 
I  compared  to  molten  fire  running  through  my  nerves. 

' '  I  began  to  hear  responses  to  and  comments  on  my  performances, 
and  it  gradually  dawned  upon  me  that  I  had  been  making  myself  a 
conspicuous  object  of  curiosity  to  the  whole  neighborhood.  .  .  .  The 
comments  heard  grew  more  numerous  and  more  and  more  derisive.  .  .  . 
I  had  no  suspicion  at  the  time  of  any  of  the  inspiration  being  drawn 
directly  from  my  head.  I  do  not  say  it  was  so.  This  is  the  debatable 
ground.    ...    It  was  not  until  about  a  week  later  that  it  became  evident 


840  MENTAL  DISEASES. 

to  me  that  I  was  hearing  my  own  thoughts  given  expression  to  by 
foreign  wills  and  voices. 

' '  I  heard  a  great  deal  about  '  inducting, '  '  conducting, '  '  sphere  of 
influence,'  sometimes  even  'poles,'  positive  and  negative,  and  my  brain 
was  constantly  compared  to  a  magnet.  ...  I  could  find  no  better 
explanation  myself  for  a  long  time  than  the  theory  of  a  fluid,  similar  to 
or  the  same  as  electricity,  uniting  brains. 

' '  One  was  the  story  of  an  English  physician  who  had  become  ac- 
quainted with  my  magnetic  properties,  and  who  was  on  the  spot  at  the 
beginning,  directing  the  experiment.  He  was  stated  to  have  been  the 
first  to  form  a  perfect  communication  with  the  inducted  brain,  and  he 
had  drawn  off  my  entire  memory  back  to  childhood,  and  had  delivered 
it  verbally  in  the  presence  of  reporters  from  the  city,  who  had  taken  it 
down.  It  was  stated  that  the  record  was  preserved  in  a  number  of  thick 
volumes.  These  he  had  taken  with  him  when  he  sailed  for  England 
during  the  most  prosperous  part  of  the  experiment.  It  was  further 
asserted  that  he  continued  in  communication  with  my  thoughts,  and 
that  wherever  he  went  every  one  to  whom  he  told  the  story  of  the  new 
marvel  was  also  set  in  connection  with  the  magnetic  current  flowing 
from  my  head,  and  began  to  participate  in  my  thoughts.  .  .  .  One 
word  more  of  the  English  doctor.  He  is  said  to  have  declared  that  if 
he  had  assisted  at  my  birth  he  would  not  have  suffered  me  to  remain 
alive,  as  the  monstrous  character  of  my  organization  could  have  been 
seen  at  a  glance.  .  .  .  After  the  whole  earth  had  become  pervaded 
with  the  magnetism  from  my  head,  it  would  be  felt  as  long  as  I  lived, 
and  the  instant  of  my  death  would  be  thus  signaled  all  over  the  globe, 
and  would  be  noted  and  used  by  all  nations  as  a  new  era  from  which  to 
reckon  time. 

"  I  would  think  of  the  Bible,  go  and  open  it  at  haphazard,  and  just 
where  my  eye  fell  there  was  a  passage  that  showed  me  myself.  Once 
when  I  had  been  fretting  about  my  ill  success  in  getting  my  mother  to 
accord  with  my  views  about  my  neighbors'  doings,  I  hit  upon  this  : 

"  'And  it  shall  come  to  pass  that  when  any  shall  yet  prophesy,  then 
his  father  and  his  mother  that  begat  him  shall  say  unto  him,  Thou 
shalt  not  live,  for  thou  speakest  lies  in  the  name  of  the  Lord  ;  and  his 
father  and  his  mother  that  begat  him  shall  thrust  him  through  when 
he  prophesieth' ,  etc. — Zechariah,  xiii. 

"But  the  most  perfect  identity  of  all  is  to  be  found  scattered 
through  the  Psalms ' '  [of  which  he  quotes  several  pages,  and  then  con- 
tinues] :  "  I  do  not  intend  to  appropriate  the  spirit  of  these  passages, 
or  to  make  their  language  my  own,  but  quote  them  thus  collectively  as 
an  evidence  of  fact.  I  am  myself  but  an  inquirer.  Do  they  express 
the  experience  of  any  certain  person  or  persons?  Or  are  they  pro- 
phetic? .  .  .  Can  it  be  that  the  same  thing  that  has  happened  to 
me  has  befallen  another  in  ages  long  past,  and  that  these  are  the  traces 
of  it? 

"I  have  also  found  a  most  remarkably  close  application  of  many 
of  the  precepts  and  reflections  of  Thomas  a  Kempis  in  his  '  Imitation 
of  Christ.'  He  seems  to  keep  the  same  character  exhibited  in  the 
Psalms  in  view,  only  speaking  as  a  monitor,  instead  of  in  his  person. 
I  presume  I  find  myself  mirrored  in  both  these  places,  because  I  am 
an  extreme  case." 

Gradually  his  delusions,  burgeoning  one  from   another,  became  so 


PARANOIA.  841 

systematized  that   in  the  last   year  of"  his  stay  at  this  asyUiin  he  could 
write  in  his  book  : 

"The  signs  are  too  many  and  too  evident  to  permit  me  to  doubt 
that  my  destiny  is  bound  up  with  the  religion  of  the  world.  I  stead- 
fastly believe  that  the  words  in  Jeremiah,  •  Take  forth  the  i^recious 
from  the  vile,'  are  addressed  to  me;  and  I  can  not  be  recreant  to  the 
holiest  of  duties.  ...  I  will  not  waste  time  in  useless  discussion, 
but  start  with  the  assumption  that  it  is  God's  will  that  I  should  give 
the  world  my  opinions. 

"If  it  comes  to  be  generally  believed  that  my  sign  is  a  fulfilment 
of  Hebrew  prophecy,  I  would  recommend  a  transfer  [of  the  Sabbath] 
to  the  day  of  the  commandment.  The  very  fact  of  a  day  one  step  re- 
moved being  fixed  on  by  both  Christians  and  Mohammedans  looks  like 
an  admission  that  another  step  remained  to  be  taken. 

' '  Was  it  not  the  confidence  of  Jesus  in  the  book  spoken  of  above 
that  made  him  say  he  knew  the  Father,  when  contending  with  believers 
in  personified  derangement?  " 

Quite  a  large  part  of  the  volume  is  devoted  to  expounding  the  Scrip- 
tures, in  accordance  with  his  delusion  that  he  is  a  prophet  come  to  re- 
veal a  new  religion. 

For  instance,  of  Babel  he  says : 

"  I  find  an  application  for  the  tower  of  Babel  in  my  own  insane 
history.  I  expect  a  confusion  of  the  speech  of  the  old  sects  to  ensue 
likewise. ' ' 

Of  Abraham  he  remarks  : 

' '  Abraham  is  accounted  the  father  of  all  who  believe  in  the  Eternal. 
I  believe  I  am  chosen  as  his  sign  for  the  abolition  of  all  dishonoring 
beliefs,  as  Abraham  was  set  up  against  all  idolators  and  pagans.  .  .  . 
I  have  to  note,  in  connection  with  the  offering  of  Isaac  by  Abraham,  that 
I  find  the  date  given  as  1872  before  Christ,  coinciding  with  the  year 
after  Christ  in  which  my  ear- troubles  commenced." 

Of  Esau : 

' '  We  may  take  Esau  for  polytheistic  religion,  recognizing  and  deify- 
ing every  force  and  passion  that  has  dominion  over  the  soul  and  destiny 
of  man.  .  .  .  When  it  gave  np  its  birthright  for  belief  in  a  single 
judge,  it  pledged  itself  to  go  on  and  submit  to  be  judged  by  the  new 
master.     I  believe  that  the  day  of  judgment  has  come." 

Of  the  miracle  of  the  rods  : 

' '  The  rods  changed  into  serpents  signify  arguments  becoming  living 
convictions  in  the  mind  of  Pharaoh.  The  evangelists'  rods  live  as  ser- 
pents in  the  minds  of  Christian  believers,  but  I  confidently  expect  that 
my  rod  will  become  a  serpent  that  wall  swallow  them  all  without  trouble. 

"Israelis  held  responsible  for  the  destruction  of  the  heathen  and 
their  idols.     I  conceive  that  I  am  the  Lord's  instrument  for  the  com- 


842  MENTAL   DISEASES. 

pletion  of  this  work,  and  that  I  have  been  shown  these  signs  in  the  law 
that  my  hands  might  be  strengthened. 

' '  I  can  not  shut  my  eyes  to  the  fact  that  I  have  been  made  the 
world' s  sin-offering. ' ' 

Of  the  prophets  : 

' '  The  prophets  I  will  take  in  a  lump,  with  the  assurance  that  no 
one  can  fail  to  see  their  connection  with  my  destiny.  There  is  a 
prophecy  in  Ezekiel,  xxxiii,  30,  which  is  very  closely  paralleled  in  my 
experience.     .     .     .     Jonah  gives  me  a  parable." 

His  discussions  of  theological  questions  are  interesting,  perfectly 
coherent  and  logical,  although  often  fanciful.  He  j)ays  tribute  to  the 
beautiful  moral  laws  and  righteousness  of  Christ,  but  is  disposed  to 
criticize  His  conduct  as  being  inconsistent  in  one  who  claimed  to  partake 
of  the  omnipotence  and  omniscience  of  the  Eternal.  Of  resurrection  he 
says  : 

"  If  I  conceive  of  a  new  body  having  the  memory  which  I  have  of 
this  body's  life, — and  I  can  find  no  other  idea  of  the  continuance  of  a 
soul's  life  except  in  the  perpetuation  or  renewal  of  the  memory, — would 
that  in  the  ncAv  body  be  a  true  memory  ?  Would  it  not  be  a  hallucina- 
tion ?     Would  not  that  be  an  insane  creation  ?  ' ' 

In  speaking  of  the  years  of  his  greatest  mental  aberration,  he  says  : 

' '  Here  I  come  to  more  debatable  territory,  on  which  I  and  the  rest 
of  the  world  have  until  this  present  been  at  variance.  I  will,  in  defer- 
ence to  the  other  side,  make  use  of  the  word  believe  in  stating  facts  drawn 
from  the  region  of  my  memory  Ijdng  within  this  shadow}^  world.  I 
will  be  permitted  to  say,  therefore,  that  I  believe  that  after  settling 
down  in  the  before-mentioned  place,  my  brain  was,  by  the  gradual 
progress  of  events  occurring  naturally  and  according  to  the  ordinary 
laws  of  human  affairs,  drawn  into  relations  to  the  living  actors  around 
me,  of  an  altogether  unexampled  kind — at  all  events,  different  from  any- 
thing plainly  recorded  in  the  annals  of  past  ages.  I  believe  that  the  final 
result  of  such  relations  was  the  superinducing  of  a  state  of  mental  inter- 
communication through  the  medium  of  my  sense  of  hearing. 

"  But  this  is  a  very  old  story,  and  merely  a  restatement  of  the  per- 
fectly well-known  features  of  my  alleged  monomania.  Let  me  pass  on 
and  give,  as  well  as  I  am  able,  my  own  theory  on  which  I  explain  these 
phenomena,  which  may  have  more  interest.  It  is  a  question  of  personal 
identification.  How  does  a  man  use  his  own  brain  ?  He  can  use  it 
because  it  recognizes  the  actions  of  his  members  as  belonging  to  the  per- 
sonal unit  of  Avhich  it  forms  the  summit.  Xow  the  question  is,  can  not 
a  human  brain  under  certain  circumstances  become  so  perverted  as  to 
recognize  for  itself,  and  without  the  volition  of  its  bearer,  the  acts  of 
other  individuals  as  belonging  to  its  life,  as  falling  within  its  own 
memory  ?  And  if  so,  would  not  those  individuals  become  partakers  of 
the  intellectuality  of  that  brain,  know  its  conceptions  and  ideas,  while 
it  thus  recognized  their  motions,  and  become  able  to  share  its  walks  and 
ways  ?  Such  I  believe  to  have  been  the  result  in  myself,  from  the 
towering  height  of  disintegration  reached  by  my  mental  organism,  by 


PARANOIA.  843 

the  gradual  process  which  I  have  endeavored  to  faintly  shadow  forth  in 
the  preceding  five  chapters. 

'  •  Let  lis  see  whether  it  does  not  look  probal^le  that  a  mind  in  the 
habit  of  separating  recognized  oliservations  from  its  own  responsibility, 
considering,  them  objectively,  philosoj^hizing  on  its  own  manner  of 
working,  driving  the  imjjotent  and  erratically  acting  part  into  a  corner, 
as  it  were,  would  not  be  more  exposed  to  such  a  fate  as  supposed  than 
one  acting  unitedly,  and  right  or  wrong  as  a  unit.  It  xm.y  not  be  sus- 
ceptible of  argument  based  on  points  of  organic  action,  but  it  looks  a 
plausible  thing  to  me  that  the  insane  quality  or  element  in  such  a  brain 
might  be  acted  on  from  without,  and  give  itself  up  to  such  action,  inde- 
pendent of  the  thinking  will  of  that  mind. 

' '  But  let  us  further  suppose  some  little  abnormality  about  the 
original  constitution,  a  predisposition  from  a  slightly  dislocated  arrange- 
ment of  mind-apparatus  and  sense-apparatus. 

•'  Such,  say  I  once  more,  I  believe  to  have  been  the  case  with  myself, 
and  such  to  be  the  true  nature  and  essence  of  the  things  which  have 
constituted  my  insanity.  .  .  .  I  do  not  deny  the  fact  of  insanity, 
but  I  firmly  believe  that  it  is  and  has  been,  since  the  summer  of  1872, 
an  insanity  involving  the  will,  ideas,  and  acts  of  more  than  one  indi- 
vidual. 

' '  Notwithstanding  my  full  and  necessary  faith  in  the  reality  of 
things  as  I  have  reasoned  to  prove  them,  I  am  still  willing  to  concede 
that  there  has  been  more  or  less  of  purely  subjective  illusion  mingled 
with  these  dual  realities.  Under  one  aspect  the  whole  of  this  train  of 
mental  images  and  impressions  which  has  whirled  through  my  head 
has  consisted  of  insane  delusion.  The  effect  on  the  state  of  my  system 
has  no  doubt  been  analogous  to  that  produced  by  delusions,  and  the 
nervous  condition  which  preceded  it  was  such  as  eventuates  in  the  rise 
of  delusions.  Does  not  the  development  of  delusions  often  have  a  com- 
pensating effect  in  freeing  the  nervous  system  in  a  manner  from  its 
trammels  ?  Perhaps  when  this  supervenes  the  brain  becomes  a  chim- 
ney for  the  combustion  of  the  matters  which  threatened  to  entirely  in- 
terrupt the  action  of  the  system  by  clogging.  The  patient  is  then 
known  as  sensible  on  most  subjects,  but  a  confirmed  monomaniac." 

Certain  peculiarities  in  his  hallucinations  possess  considerable  in- 
terest. They  almost  always  referred  to  the  intercommunication  of 
brains.  In  July,  1878,  he  wrote  out  a  list  of  specimen  phrases 
which  he  had  heard  while  sitting  alone  at  an  asylum  window.  Some 
of  these  I  reproduce  here  : 

' '  One  thing  you  know,  you  know  when  3^011  get  your  will  in  there 
3^011  get  him  into  a  hell  of  misery." — "  He  ain't  got  any  will  there  to 
fool  away." — "Although  you  are  knowing  his  ideas  you  connect  with 
her  will." — "  Instead  of  connecting  with  his  ideas  you  keep  giving  him 
to  her." — "You  can't  get  your  will  there  till  he  connects  his  through 
to  his  thought." — "We  are  all  the  while  trying  to  make  him  think 
himself." — "  I  think  we  ought  to  be  making  efforts  to  get  the  idea  out 
on  the  hall." — "After  they  get  the  whole  will  he  is  in  a  hell  of  torture 
all  the  while." — "We  keep  hollering  till  we  get  him  into  a  hell  of  hor- 
rors."— "  You  see,  Avhen  there  are  two  wills  connected  with  the  head  at 
the  same  time,  he  ain't  nowhere." 


844  MENTAL   DISEASES. 

These  were  the  voices  of  several  men  and  women.  In  fact,  his  hal- 
hicinations  were  always  polyphonic,  and  at  times  would  be  polyglot. 
They  did  not  address  him  directly,  but  sjDoke  to  one  another  about  him. 
He  seldom  had  hallucinations  of  hearing  except  when  the  ear  actually 
received  the  sound  of  distant  conversation  or  inarticulate  noises  ;  so  that 
for  their  production  it  was  usually  necessary  that  there  should  be  trans- 
mission of  vibrations  to  the  auditory  cortical  area.  As  instances  of  the 
polyglot  character  of  the  voices  on  occasion,  I  relate  the  following  : 

Once  he  heard  some  one  call  out,  "  If  he  ain't  a  prophet  there  never 
was  a  prophet — tabulas  dedi  ut  vincerer."  In  tracing  this  Latin  to  its 
source,  he  found  it  was  a  perversion  of  a  phrase  in  a  note  to  Whis- 
ton's  "  Josephus  "  :  "  Egomet  tabulas  detuli  ut  vincerer  "  (I  myself  car- 
ried the  letter  commanding  that  I  be  bound),  attributed  to  Bellerophon, 
which  he  had  once  read. 

At  another  time  in  a  street-car,  a  German  sitting  next  to  him  cried 
out,  "  Das  ist  das  gr5sste  Mirakel  von  der  ganzen  Welt.  Jeder 
Gedanke  der  ihm  in  den  Kopf  gekommen  ist  hat  die  gauze  Village 
gehort."  (That  is  the  greatest  miracle  in  the  world.  The  whole  vil- 
lage has  heard  every  thought  that  has  come  into  his  head.)  The  gram- 
matical construction  of  the  foreign  phrases  is  open  to  criticism.  The 
language  used  by  his  invisible  tormentors  was  always  a  peculiar  dialect, 
often  abounding  in  slang,  which  he  considered  the  most  hateful  kind 
of  language,  and  which  was  such  as  he  never  voluntarily  used  in  the 
composition  of  his  own  sentences.  The  hallucinations  were  usually 
boisterously  satirical,  teasing,  quizzical,  frequently  accompanied  by 
laughter. 

Course  and  Prognosis. — The  usual  course  of  paranoia  has  just 
been  outlined.  Many  cases,  however,  enter  into  a  state  of  secondary 
dementia  toward  the  last. 

The  prognosis  is  absolutely  unfavorable.  I  do  not  know  of  a  single 
case  that  has  recovered.  These  patients  may  live  to  an  advanced  age, 
especially  under  the  fostering  care  of  an  asylum.  Remissions  are 
occasionally  noted. 

Morbid  Anatomy. — The  disorder  is  purely  functional.  No  patho- 
logical changes  have  been  found  in  the  brains  of  paranoiacs.  In  some 
instances  asymmetrical  arrangement  of  the  convolutions  has  been  noted. 
These  belong  in  the  category  of  stigmata  of  degeneration. 

Treatment. — Therapy  does  little  or  nothing  for  the  disease  once  it 
has  become  established.  Sometimes  complete  change  of  environment 
brings  about  a  remission.  Constant  physical  occupation,  hard  work 
out-of-doors,  is  perhaps  the  most  useful  of  remedial  agents,  in  that  by 
this  means  the  mind  is  diverted  from  the  constant  contemplation  of 
hallucinations  and  delusions,  and  through  bodily  fatigue  is  made  to 
receive  a  considerable  amount  of  repose.  Labor  acts  as  a  counterirri- 
tant.  By  it  episodic  outbreaks  of  excitement  may  be  aborted  or 
reduced  in  intensity.  Prevention  naturally  Avould  be  of  vast  impor- 
tance, were  one  able  to  anticipate  the  coming  catastrophe  in  the  pro- 
dromal period.  Children  and  youths  who  exhibit  such  symptoms  as 
have  been  described  as  incident  to  the  hypochondriacal  epoch   of  the 


IDIOCY.  845 

evolution  of  paranoia  require  a  special  system  of  education  and  train- 
ing, in  which  occupation  of  the  muscles  and  out-of-door  life  should 
play  the  chief  role. 


CHAPTER  XIII. 
IDIOCY, 

Definition. — In  attempting  to  make  a  good  definition  and  prepare 
a  classification  of  idiocy,  we  meet  with  much  the  same  difficulties  as 
exist  in  connection  with  the  allied  subject  of  insanity.  The  innum- 
erable definitions  and  classifications  of  insanity  by  different  authorities 
are  familiar  to  all  students  of  morbid  psychology.  Each  author  feels 
called  upon  to  be  original  in  this  particular,  or  at  least  to  modify  and 
improve  upon  the  dicta  of  previous  writers.  This  confusion  is  quite 
parallel  in  the  matter  of  idiocy  ;  and  it  is  easy  to  understand  why  this 
should  be  so,  for  in  both  conditions  we  have  deviations  from  the  normal 
mental  state  of  every  possible  shade  and  degree,  depending  upon  a  most 
varied  pathology.  The  etiology  is  complex,  and  the  psychic  and 
somatic  symptomatology  multiform.  There  is  no  wonder,  then,  that 
the  clinical  picture  is  hard  to  draw,  and  the  arrangement  into  clinical 
types  difficult  in  the  extreme.  It  is  impossible  to  make  any  comparison 
between  the  psychological  state  of  idiots  and  that  of  normal  children, 
for  the  former  is  not  only  one  in  which  the  mental  faculties  are 
diversely  undeveloped  or  impaired  as  regards  their  quantity,  but  there 
is  infinite  variation  in  the  quality  of  the  idiot's  psychic  functions. 
Likewise  it  is  impossible  to  contrast  the  mental  organization  of  the  idiot 
with  the  intelligence  of  the  lower  animals,  for  the  idiot  is  always 
abnormal,  while  the  animal  is  a  normal  being  in  the  zoological  series  to 
which  he  belongs. 

What  seems  to  be  desirable  in  a  definition  is  that  there  should  be 
expressed  in  it  the  condition  of  mental  weakness  existing,  the  facts  that 
the  condition  may  be  congenital  or  acquired,  and  may  be  due  to  a 
defect  or  some  disease  of  the  brain,  and,  further,  that  the  condition  is 
one  belonging  to  the  developmental  period  of  life.  A  definition  some- 
thing like  the  following  would  seem  to  me  to  fairly  express  these 
desirable  points  :   ^ 

Idiocy  is  mental  feebleness  due  to  disease  or  defect  of  the  hrain,  con- 
gemtal  or  acquired  during  its  development. 

Classification. — As  regards  classifications,  they  have  been  made 
upon  a  basis  of  symptomatology,  psychology,  etiology,  craniology, 
teratology,  and,  to  a  certain  extent,  of  pathology.  But  it  seems  to  the 
writer  that  the  time  is  not  yet  come  for  an  accurately  scientific  classi- 
fication of  the  forms  of  idiocy.  It  is  much  the  best  plan  at  present  to 
adopt  an  artificial   grouping,  chiefly   clinical,  but  pathological   to   the 


846 


3IENTAL  DISEASES. 


Fig.  315. — Diplegia  idiot. 


Fig.  316 — Extreme  hydrocephalic  idiocy,  ■n-ith  diplegia. 


IDIOCY. 


847 


Fig.  317. — Cretiu  aged  thirteen  years  standing  beside  normal  brother  aged  lour  years  i  showing  dwarf- 
ing of  growth). 


Fig.  318. — Hydrocephalic  imbecile. 


Fig.  319. — Idiot  with  multiple  sclerosis. 


848 


3IENTA  L    DISEA  SES. 


Fig.  320.— Microcephalic  idiocy — wild,  restless,  quar-  Fig.  321.— Hydrocephalic  feeble- 

relsome,  perverted.  mindedness. 


Fig.  322. — Microcephalic  idiocy. 


Fig.  323  —Paraplegic  idiocy. 


IDIOCY. 


849 


Fig.  324. — Microcephalic  imbecile— good-natured  Fig.  325.— Good-uatured  imbecile— fair 

and  a  fair  worker.  worker. 


Fig.  326.— Two  epileptic  idiots 


54 


850  MENTAL   DISEASES. 

extent  of  our  latest  knowledge.  Almost  any  of  the  types  of  the 
divisions  here  made  use  of  may  be  congenital  or  acquired.  The  term 
idiocy  itself  is  generic,  including  as  it  does  all  degrees  of  mental 
impairment  in  early  life.  But  the  variations  in  degree  or  intensity  of 
the  mental  weakness  are  indicated  by  the  expressions  :  idiocy,  for  the 
lowest  degree  of  mental  disability  ;  imbecility,  for  a  higher  degree,  and 
feeble-mindedness,  for  the  cases  of  idiocy  in  which  the  psychic  faculties 
have  their  highest  development.  There  is  some  confusion  in  literature 
as  to  the  exact  limitation  and  application  of  these  degrees.  Sollier  has 
made  an  attempt  to  distinguish  idiocy  and  imbecility,  but  his  definition 
of  imbecility  is  not  tenable,  in  the  opinion  of  the  writer,  for  he 
describes  a  certain  small  class  of  imbeciles  as  representative  of  the 
whole  order.  It  is  to  be  remembered  that  in  each  of  these  degrees  we 
have  many  gradations,  and  the  entire  series,  from  absolute  idiocy  to  a 
normal  state,  leads  up  by  progressive  stages  through  various  types  of 
idiocy,  several  steps  of  imbecility,  and  numerous  shades  of  feeble- 
mindedness, until  the  borderland  between  the  highest  degenerate  and 
the  normal  individual  is  almost  indefinable. 

The  highest  group  includes  a  rather  well-defined  class  of  feeble- 
minded :  the  "backward  children,"  the  enfants  arrier^s  of  the  French, 
the  tardivi  of  the  Italians,  and  the  Geistig-zuruclcgebliebene  of  the  Germans. 
The  difficulty  is  not  so  much  in  the  delimitation  of  this  class,  as  in  the 
separation  of  the  group  of  idiots  and  imbeciles.  It  is  easy  to  make  the 
classification  on  seeing  the  cases,  but  to  convey  to  others  the  differentia- 
tion by  description  is  far  from  being  so,  because  of  the  many  features — 
physical,  motor,  and  mental — which  are  concerned  in  such  division. 
The  writer,  while  employing  the  term  idiocy  often  to  include  all  of 
these  degrees,  would  define  the  idiot  proper  as  an  individual  able  to 
give  little  or  no  care  to  his  person  ;  incapable  of  intelligent  com- 
munication, barely  able  to  express  his  material  wants,  most  awk- 
ward and  ungainly  in  his  movements,  if  he  move  at  all,  and  presenting 
marked  evidence  in  his  lack  of  expression,  apathetic  attitudes,  and  physi- 
cal stigmata  of  degeneration,  of  tlie  profound  stunting  of  his  mental  and 
physical  development.  On  the  other  hand,  the  imbecile  is  able  to  care 
for  his  person  and  dress,  attend  to  his  physical  wants,  comprehend 
fairly  what  is  said  to  hira,  carry  out  orders  more  or  less  intelligently,  is 
often  able  to  speak  well  (though  sometimes  speech  may  be  impossible 
to  a  very  intelligent  imbecile)  ;  if  not  paralyzed,  he  has  good  use  of  all 
his  muscles ;  he  is  not  destitute  of  expression,  though  the  expression 
may  vary  from  an  evil,  mischievous,  cunning  cast  of  countenance  to 
one  of  rollicking  good  nature  ;  there  are  fewer  stigmata  of  degenera- 
tion in  this  class  than  among;  idiots. 

The  clinicopathological  grouping  of  the  varieties  of  idiocy  which 
the  writer  has  found  most  useful  to  him  in  his  work  at  the  Randall' s- 
Island  Hospital  for  Idiots  is  as  follows  : 

1.  Hydrocephalic  idiocy. 

2.  Microcephalic  idiocy. 

3.  Paralytic  idiocy. 

4.  Epileptic  idiocy. 


Fig.  327, — Epileptic  idiocy. 


Fig.  328  — Imbecile,  with  extreme  dolichocephaly. 
I  Lenjiih-breadth  iudex,  .51.  i 


Fig.  329. — Hemiplegic  idiocy. 
(Blainville  eav.s. ) 


Fig.  330. — Microcephalic  imbecile. 


Fig.  331. — Idiocy  as  a  result  of  dementia  from  acute 
insanity  in  childhood. 


Fig.  332.— Epileptic  idiocy. 


851 


852  MENTAL   DISEASES. 

5.  Traumatic  idiocy. 

6.  Sensorial  idiocy. 

7.  Meningitic  idiocy. 

8.  Myxedematous  idiocy,  or  cretinism. 

9.  Amaurotic  idiocy. 
10.  Idiots  savants. 

It  is  impossible,  in  the  brief  space  allotted  this  subject,  to  discuss 
these  various  forms  of  idiocy  in  detail.  The  reader  must  be  referred 
to  special  works  and  articles  on  idiocy — to  the  general  works  of  Downs, 
Shuttleworth,  Voisin,  Sollier,  etc. — and  to  the  monographs  by  the 
writer  and  others.  Hydrocephalic,  microcephalic,  paralytic,  epileptic, 
and  traumatic  idiocy  are  readily  recognized  by  their  symptoms  or  history. 
Sensorial  idiocy  is  a  form  due  to  the  congenital  or  early  loss  of  two 
such  senses  as  sight  and  hearing.  Properly  treated,  these  patients  are 
capable  of  normal  mental  development  (Helen  Kellar  and  Laura  Bridg- 
man).  Meningitic  idiocy  can  usually  be  diagnosticated  only  by  autopsy, 
unless  the  history  or  exacerbations  in  the  course  of  the  disease  demon- 
strate its  origin.  Cretinism  is  a  rare  form  which  has  been  fully 
described  in  many  brochures  in  recent  years.  The  amaurotic  form  is 
still  rarer.  There  are  only  two  of  these  in  the  Randall's  Island 
Asylum  among  many  hundreds  of  idiots. 

The  term  idiots  savants  is  applied  to  all  such  idiots,  imbeciles,  or 
feeble-minded  as  exhibit  special  aptitudes  of  one  kind  or  another, 
always  out  of  proportion  to  their  intellectual  development  in  other 
directions,  and  often  remarkable  as  compared  with  similar  accomplish- 
ments or  faculties  in  normal  individuals. 

There  are  many  cases  of  the  kind  recorded  in  literature,  and  it  is 
not  at  all  uncommon  to  hear  of  idiots  in  our  newspapers  and  museums 
who  are  exhibited  as  musical  prodigies,  "calculating  boys,"  and  the 
like.  Beyond  the  fact  of  the  existence  of  such  curiosities,  and  the  record 
of  their  deeds,  there  has  been  little  or  nothing  written  in  explanation  of 
these  phenomena.  The  psychology  of  the  condition  is  exceedingly 
ol>scure  ;  and  even  were  the  psychological  processes  which  underlie  special 
aptitudes  understood,  there  would  still  remain  the  mystery  of  the  mani- 
festation of  particular  talents  or  faculties  in  minds  otherwise  blank  or 
defective. 

The  aptitudes  may  be  summarized  as  follows  : 

Arithmetical  faculty,  musical  faculty,  special  memories,  imitative 
faculty,  modeling  faculty,  clelineative  faculty,  faculty*  for  painting,  apti- 
tude for  games  (draughts,  etc.),  aptitude  for  ]~)uifoonery.  (See  article  by 
author  on  ■"  Idiots  Savants  "  in  Appleton's  "  Popular  Science  Monthly," 
December,  1896,  in  which  a  history  of  some  remarkable  examples  is 
given.     See  also  page  855  of  this  book.) 

General  Etiology. — There  are  nearly  twice  as  many  male  as  female 
idiots.  In  idiocy  due  to  prolonged  or  difficult  labor,  this  disproportion 
is  even  larger  (three  males  to  one  female) — a  fact  to  be  explained  probably 
by  the  larger  size  of  the  male  infant.  The  causes  of  idiocy  may  be  classi- 
fied as  follows  : 


IDIOCY. 


853 


Fig.  333. — Paraplegic  idiocy. 


Fig.  384. — Idiocy  after  acute  insanity  of  childhood, 
l-'eeuliar  tic  of  fingers. 


Fig.  335. — Two  imbeciles,  one  epileptic  and  one  of  unknown  origin  (both  homosexual  perverts). 


854 


MENTAL  DISEASES. 


Hereditary  transformation  of  nervous  and  mental  diseases. 
Pathological  heredity  in  the  form  of  vitiating  diseases  or  habits  (tu- 
Degenerative  \     berculosis,  rheumatism,  gout,  herpetism,  syphilis,  alcoholism,  etc.). 
Sociological  factors  (extreme  youth   of   parents,    extreme   age  of 
parents,  disproportionate  age  of  parents,  consanguinity). 


Adventitious 


Maternal 


Trauma,  shock,  fright,  diseases,  maternal 
impressions. 


Gi-estational 


V  t-\  f  Syphilis,  heart  disease,  arteritis,  morbid 
J-..  ^  ^  \  processes  in  the  brain  and  meninges, 
uisoraers  ^      ^^-^^  pregnancy. 


Parturi- 
tional 


f  Difficult  labor,  primogeniture,  premature  birth, 
\  asphyxia  at  birth,  instrumental  injuries,  pressure 
I      on  the  cord. 


{Convulsions,  cerebral  diseases,  trauma  to  the  head, 
febrile  diseases,  mental  shock,  sunstroke,  over- 
pressure at  school. 


The  relations  of  heredity  to  idiocy  are  much  the  same  as  those  of 
heredity  to  the  psychoses  described  in  the  chapter  on  General  Etiology  of 
Insanity.  The  statistics  available  (snch  as  those  of  Shuttleworth  and 
Beach,  Langdon  Down,  Kerlin,  and  Piper)  seem  to  show  neurotic  in- 
heritance in  about  forty  to  fifty  per  cent,  of  idiots.  The  stigmata  of 
degeneration,  which  are  so  marked  in  idiocy,  are  described  in  an  earlier 
chapter.  As  regards  titberculosis  and  scrofula  in  the  parents,  the  per- 
centages of  these  authors  vary  from  fifteen  to  thirty  per  cent.  Alco- 
holism takes  a  high  place  among  the  causes  of  progressive  hereditary 
degeneration  (nine  to  sixteen  per  cent.).  The  writer  has  found  that 
hereditary  syphilis  is  a  comparatively  rarer  cause  of  idiocy  than  many 
would  suppose,  and  this  is  supported  by  the  statistics  of  the  authors 
named  above  (one  to  two  per  cent.).  As  regards  consanguinity,  the  sta- 
tistics show  that  the  proportion  of  idiotic  offspring  of  cousins  to  the 
number  of  idiots  is  very  slightly  in  excess  of  the  number  of  consanguin- 
eous marriages  to  marriages  in  general. 

Gestational  causes  vary,  according  to  the  statistics,  from  eleven  to 
thirty  per  cent.  Parturitional  factors  (meningeal  hemorrhage  from 
prolonged  labor,  asphyxia  at  birth,  premature  birth,  pressure  on  the 
cord,  forceps  injuries,  etc.)  are  active  in  about  eighteen  per  cent.  It 
may  be  said  that  forceps  injuries  are  far  less  dangerous  to  the  child  than 
tedious  labor.  Among  adventitious  causes  infantile  convulsions  occupy 
a  preeminent  position  (over  25  per  cent.).  But  we  must  remember 
that  the  convulsions  may  act  as  a  real  cause,  by  inducing  meningeal 
hemorrhage ;  or  convulsions  may  be  merely  an  associated  symptom  of 
a  meningeal  hemorrhage  or  other  pathological  condition  due  to  some 
other  common  factor.  Cerebral  diseases  (meningitis,  hydrocephahis, 
hemorrhage,  thrombosis,  embolism,  tumor,  and  abscess)  follow  infantile 
convulsions  in  the  statistical  table  of  causes  (eight  to  nine  per  cent.). 

Acute  febrile  diseases  induce  idiocy  in  some  six  per  cent,   of  cases. 


IDIOf'Y.  855 

These  diseases  are  scarlet  fever,  measles,  whooping-cough,  typhi  lid 
fever,  small-pox,  and  diphtheria.  How  they  act  is  not  yet  known. 
Sometimes  it  is  through  meningeal  hemorrhage  induced  by  the  convul- 
sions so  common  at  tlie  onset  or  during  the  course  of  these  maladies. 
Possibly  at  other  times  it  is  through  an  infectious  encephalitis,  or 
microbic  embolism  or  thrombosis.  Trauma  to  the  head,  mental  shock, 
sunstroke,  and  ''  cramming "  at  school  have  a  small,  yet  appreciable, 
share  in  the  production  of  idiocy  (probably  two  to  five  per  cent,  alto- 
gether). The  author  has  found,  in  his  own  experience,  that  insanity  in 
children  is  an  occasional  cause  of  idiocy.  In  the  adult  such  mental 
enfeeblement  after  insanity  is  a  secondary  dementia,  but  in  the  growing 
child  this  secondary  dementia  is  preferably  termed  idiocy. 

General  Symptomatology. — Since  idiocy,  as  well  as  its  varying 
degrees  of  imbecility  and  feeble-mindedness,  depends  upon  some  sort 
of  congenital  or  acquired  defect  or  disease  of  the  brain  interfering 
with  its  normal  evolution,  it  is  clear  that  the  cerebral  functions  may 
be  all  of  them  more  or  less  involved,  and  that  no  particular  psychic 
faculty  can  be  selected  as  the  one  whose  disorder  retards  or  influences 
the  development  of  the  other  faculties.  Seguin  is,  therefore,  hardly 
correct  in  stating  that  the  condition  of  the  mental  faculties  in  idiots  is 
normal,  though  diminished,  and  that  merely  the  will  is  lacking  to 
give  them  proper  direction.  Sollier  has  given  us  one  of  the  best  and 
latest  studies  of  the  psychology  of  idiocy.  ^  Following  Ribot  and 
others,  he  maintains  that  the  slow  development  of  the  cerebral  facul- 
ties is  due  to  want  of  attention ;  that  spontaneous  attention  is  caused  by 
affective  states  brought  into  action  by  sensations,  and  that  those  young 
children  are  the  most  attentive  whose  nervous  systems  are  most  easily 
stimulated.  Hence  the  faculty  of  attention  is  closely  related  to  the 
activity  of  the  sensations.  The  greater  the  power  of  attention,  the 
more  intelligent  does  the  individual  become.  In  idiocy,  owing  to  the 
diminution  or  loss  of  the  power  of  attention,  the  perceptions  aroused  by 
sensations  are  more  or  less  indefinite,  and  the  resultant  idea  likewise 
ill-defined.  Sensations  become  more  numerous  as  the  organism  develops, 
and  the  lack  of  ideas  and  recognitions  becomes  more  noticeable. 

Following  somewhat  the  natural  order  of  such  examination,  with  the 
excellent  work  of  Sollier^  as  a  guide,  we  first  take  up  the  senses,  those 
avenues  which  lead  to  psychological  development. 

Sight. — Between  seven  and  eight  per  cent,  of  idiots  are  congenitally 
blind.  It  is  necessary  to  determine  whether  the  blindness  is  due  to 
defect  of  the  visual  apparatus  or  to  lack  of  attention.  Blindness  does 
not  preclude  the  possibility  of  education,  for  some  idiots  with  defect 
of  this  sense  may  be  educated  to  a  moderate  degree.  AVhen  idiots  can 
look,  without  in  reality  seeing,  the  apparent  blindness  is  due  to  a  com- 
plete absence  of  attention.  In  idiots  less  aflPeeted,  a  greater  variety  of 
objects  will  attract  their  attention.  In  the  higher  grades  of  idiocy 
(imbecility  and   feeble-mindedness)  vision  may  be  as  good  as  in  normal 

^  "Psychologic  de  I'idiot  et  de  I'imbecile,"  Paris,  1891. 

^  The  anther,  while  differino;  from  Sollier  materially  in  some  of  his  conclusions,  is 
indebted  to  his  work  for  many  of  the  details  of  the  psychological  symptoms  of  idiocy. 


856  MENTAL  DISEASES. 

Dian.  But  many  present  certain  visual  and  ocular  defects,  such  as 
hypermetropia,  defective  color-vision,  strabismus,  nystagmus,  congenital 
cataract,  inequality  of  the  pupils,  microphthalmos,  and  the  like.  In 
hemiplegic  idiocy  or  imbecility  we  may  find  hemianopia.  But  the  de- 
termination of  the  acuity  of  vision  is  difficult  in  this  class  of  individuals. 
The  perception  of  diiferent  colors  is  often  possible  in  the  milder  degrees 
of  idiocy.  Good  binocular  vision  is  uncommon  in  idiots.  The  normal 
child  takes  pleasure  in  the  sight  of  objects  as  early  as  the  eleventh  day, 
the  eyes  are  normally  coordinated  by  the  end  of  the  second  month,  and 
he  begins  to  distinguish  colors  correctly  at  about  the  age  of  two  years. 

Hearing. — There  is  a  somewhat  analogous  condition  of  the  organs 
of  hearing.  It  is  not  always  easy  to  determine  whether  an  idiot  is  deaf 
from  defect  in  the  auditory  apparatus  or  only  sensorially  deaf.  Idiocy 
of  mild  degree  is  not  infrequently  induced  by  deprivation  of  this  sense. 
In  the  higher  grades  of  idiocy  hearing  is  nearly  always  normal.  Deaf- 
mutism  can  not  be  considered  as  common.  The  normal  child  hears  on 
the  fourth  day,  and  is  pleased  with  music  in  the  second  month. 

Taste. — This  sense  is  frequently  affected.  Gluttony  is  a  marked 
feature  in  idiocy.  It  is  common  for  idiots  to  eat  without  mastication  ; 
many  present  a  precocious  taste  for  alcohol.  This  is  especially  true 
of  the  higher  grades.  A  difficulty  in  distinguishing  the  simple  tastes 
(salt,  sweet,  bitter,  and  sour)  is  not  infrequently  met  with  in  the  milder 
types,  as  well  as  in  those  with  great  mental  impairment.  Inversions 
and-  perversions  of  taste  are  observed.  The  normal  child  evinces  a 
sensibility  to  taste  at  the  end  of  the  first  week. 

Smell. — In  the  normal  child  strong-smelling  substances  produce 
mimetic  movements  on  the  day  of  birth.  In  idiocy  the  sense  may  be 
much  impaired,  perverted,  or  absent. 

Tactile  Pain  and  Muscular  Sensibility. — As  a  rule,  sensibility 
to  touch  and  pain  is  uniformly  diminished  in  idiocy  of  all  degrees, 
mostly  through  lack  of  attention.  There  may  be  complete  anesthesia 
and  analgesia,  particularly  in  the  lower  grades.  On  the  other  hand, 
there  are  cases  in  which  the  sense  of  touch  may  be  educated  to  a  high 
degree  of  delicacy.  It  is  almost  impossible  to  study  the  muscular  sense 
in  idiots,  but  it  is  apt  to  be  impaired  in  proportion  to  the  other  senses. 
The  normal  child  starts  at  gentle  touches  on  the  second  and  third  days, 
and  manifests  muscular  sense  as  early  as  the  eighth  week. 

Thermic  Sensibility. — What  has  been  said  of  touch  and  pain 
applies  likewise  to  the  temperature  sense.  But  their  vasomotor 
systems  are  susceptible  to  the  influences  of  cold  and  exposure,  and  their 
resistance  to  external  influences  and  diseases  is  such  that  many  of  them 
die  of  pulmonary  affections.  Some  become  more  stupid  in  cold  weather 
and  brighter  in  warm  weather,  while  an  elevation  of  bodily  tempera- 
ture (fever)  is  accompanied  by  evidences  of  more  active  cerebration. 

Morbid  Movements. — A  small  number  of  idiots  exhibit  no  motility 
at  all,  but  remain  perfectly  inert.  But  the  majority  are  apt  to  be  in 
constant  motion.  These  movements  tend  to  take  on  a  rhythmic  and 
automatic  character.  I  do  not  here  refer  to  such  morbid  movements  as 
epilepsy,    athetosis,  associated    movements,    ataxia,    and    chorea,   often 


IDIOCY.  857 

present  in  paralytic  idiocy ;  nor  to  tremor,  found  in  sclerotic  cases  ;  but 
to  a  group  of  automatic  or  impulsive  movements. 

These  forms  of  mova-ments  are  auiong  the  most  connuou  and  striking 
symptoms  immediately  noticed  in  going  through  an  institution  for  idiots. 
A  very  large  proportion  of  the  inmates  are  observed  to  be  in  continual 
motion.  As  a  rule,  the  most  frequent  rhythmic  movement  is  an 
anteroposterior  oscillation.  The  patient,  in  a  sitting  attitude,  sways 
his  body  slowly  or  rapidly  backward  and  forward.  Sometimes  the 
oscillation  is  from  side  to  side.  Occasionally  the  hands  and  fingers  are 
rapidly  or  slowly  flexed  and  extended,  and  brought. up  to  the  face  in 
movements  similar  to  those  in  athetosis,  but  differing  from  them  in  that 
they  are  entirely  subject  to  the  will,  just  as  are  the  oscillations  alluded 
to.  Walking  to  and  fro,  rotating,  dancing,  and  so  on,  are  more  elab- 
orate forms  of  the  same  kind  of  impulsive  movement.  Similar  move- 
ments occur  in  the  insane,  as  is  well  known,  and  particularly  in 
conditions  of  greatly  enfeebled  mind,  such  as  secondary  dementia. 
They  are  spontaneous  movements,  seeming  to  have  no  relation  to  any 
stimulation  of  the  brain  giving  rise  to  a  motor  expression.  Generally 
the  movements  cease  for  a  time  when  any  sensory  impression,  such  as 
the  appearance  of  a  stranger  in  the  room  or  being  spoken  to,  temporarily 
alters  the  feeble  current  of  thought  or  excites  the  mental  blankness 
Avhich  has  given  rise  to  the  automatic  movement.  Children  and  young 
animals  are  full  of  spontaneous  movements,  undoubtedly  due  to  impres- 
sions received  at  some  time  during  their  lives,  or,  it  may  be,  impres- 
sions inherited ;  and,  while  these  spontaneous  movements  of  children 
are  undoubtedly  similar  in  their  nature  to  the  automatic  movements  of 
dements  and  idiots  just  described,  they  do  not  often  present  the 
rhythmic  character  of  the  latter.  It  is  probable  that  in  the  feeble 
mind,  upon  which  nerve  stimuli  seldom  make  an  impression,  the  simple 
old  motor  expressions  are  retained,  repeated,  and  become  habitual  or 
automatic.  Automatism  of  movement  is  thus  a  sign  of  little  aptitude 
or  impressionability,  so  far  as  fresh  mental  stimulation  is  concerned. 
In  the  idiot  the  impulsive  rhythmic  movements  just  described  may  be 
regarded  as  the  habitual  motor  expression  of  the  simplest  and  oldest 
stimuli ;  whereas,  in  the  secondary  dement,  the  analogous  automatic 
movements  are  to  be  looked  upon  as  reversions  to  the  spontaneous 
movements  of  infancy.  The  smiles  and  grimaces  of  idiots  and  imbeciles 
belong  to  the  same  category  of  infantile  spontaneous  motor  expressions. 

There  is  probably  a  certain  amount  of  pleasure  in  the  movements 
in  many  cases,  as  sometimes  they  manifest  displeasure  if  prevented 
from  executing  tliem.  There  is  nearly  always  a  difficulty  out  of  pro- 
portion to  the  intellectual  development  for  idiots  to  perform  associated 
movements  with  a  definite  object.  They  may  be  able  to  talk  and  read, 
and  even  w^rite,  yet  be  unable  to  dress  themselves.  This  is  often  a  fault 
remediable  by  education,  according  to  Seguin. 

Rig-ht-handedness  and  Left-handedness. — Some  twelve  per  cent, 
of  all  children,  idiot  and  normal,  are  left-handed  ;  but  while  eighty-eight 
per  cent,  of  normal  children  are  right-handed,  only  seventy-two  per  cent, 
of  idiots  use  their  right  hand  in  preference,  the   remaining   sixteen  per 


858  MENTAL  DISEASES. 

cent,  beinii;  ambidextrous.  This  peculiarity  is  said  to  be  present  also 
among  criminals. 

Voluntary  Movements. — Many  idiots  do  not  learn  to  walk  at  all, 
either  because  of  general  debility,  inability  to  learn,  or  paralysis.  In 
such  as  do  acquire  the  ability  to  walk  there  is  great  retardation  in  its 
acquisition.  This  is  also  true  of  other  uses  of  the  voluntary  muscles 
for  the  common  acts  of  daily  life,  such  as  carrying  food  to  the  mouth, 
and  so  on.     They  are  either  never  learned  or  they  are  acquired  late. 

Organic  Sensations. — The  keenness  of  visceral  sensibility  is 
more  or  less  diminished  in  all  idiots.  The  sensations  of  hunger  and 
thirst  are  lessened,  though  only  very  rarely  absent.  The  feeling  of 
satiety  after  a  hearty  meal  is  seldom  felt  by  them ;  so  that  if  left  to 
themselves,  they  would  eat  on  indefinitely.  The  necessity  of  defecation 
and  micturition  is  not  perceived  at  all  by  profound  idiots.  In  the 
lower  and  middle  grades  of  idiocy  it  is  often  difficult  to  diagnosticate 
visceral  disease,  owing  to  the  bluntness  of  somatic  sensations,  and  they 
may  die  without  giving  any  appreciable  symptoms.  This  masking  of 
disease  in  idiocy  is  quite  analogous  to  the  masking  of  disease  in  various 
insanities.  The  feeble-minded  and  imbeciles  not  infrequently  mislead 
the  physician  by  exaggeration,  concealment,  or  falsehood. 

Attention. — The  lack  of  the  faculty  of  attention  is  one  of  the 
chief  characteristics  of  idiocy.  Naturally,  it  varies  in  degree  from 
complete  nullity  to  a  simple  diminution  of  the  faculty,  but  it  is  always 
lessened.  The  fundamental  elements  of  the  faculty  are  deficient. 
These  fundamental  elements  are  :  The  integrity  of  sensory  impressions 
delivered  to  the  brain  ;  an  emotional  state  of  pleasure,  pain,  or  interest 
in  such  sensations ;  motor  expressions  in  the  eyes,  face,  limbs,  or  body 
of  the  impressions  received.  There  are  two  forms  of  attention,  accord- 
ing to  Ribot  and  Sollier,  one  of  which  is  natural  or  spontaneous,  and 
the  other  voluntary,  established  by  education.  The  latter  can  not 
exist  without  the  former. 

There  are  two  qualities  in  attention  that  are  of  importance — viz., 
intensity  and  duration. 

Thus,  attention  is  impaired  in  idiocy  by  the  defective  senses,  which 
convey  to  the  brain  feeble  impressions.  The  second  element,  the  affec- 
tive state,  is  notal)ly  lacking  in  idiots.  The  motor  factor  of  attention 
is  deranged  in  idiocy  in  a  great  variety  of  ways  (general  weakness, 
paralysis,  contracture,  epilepsy,  chorea,  ataxia,  automatic  and  impul- 
sive movements,  and  the  like).  The  intensity  and  duration  of  attention 
are  restricted  to  the  last  degree  in  this  class  of  individuals. 

The  intelligence  and  the  possibility  of  education  depend  directly 
upon  the  power  of  the  faculty  of  both  spontaneous  and  voluntary  at- 
tention. It  is  j)robable  that  the  faculty  is  localized  chiefly  in  the  frontal 
lobes  of  the  brain.  Ferrier  considers  it  proportionate  to  the  develop- 
ment of  these  lobes,  and  some  very  convincing  experiments  recently 
published  by  Bianchi  make  it  quite  certain  that  the  frontal  lobes  are  the 
seat  of  this  faculty.  In  idiots  great  lack  of  attention  is  coincident  with 
diminutive  size  of  the  frontal  lobes. 

In  the  low  grades  of  idiocy  spontaneous  attention   is   almost  null. 


IDIOCY.  859 

and  education  is  impossible.  The  higher  the  degree  of  idiocy,  the 
greater  the  degree  of"  spontaneous  attention  presented,  which  may  be  so 
appealed  to  as  to  develop  it  into  voluntary  attention,  with  intellectual 
progress  as  a  consequence.  With  idiots,  as  with  the  lower  animals,  at- 
tention is  always  connected  with  the  sense  most  perfectly  developed, 
which,  in  the  former,  is  that  of  sight.  The  attention  of  idiots  is  most 
easily  aroused  through  the  eyes.  Exercises  of  the  attention  may  thus 
be  employed  in  the  diagnosis  of  states  of  intellectual  weakness.  We 
find  idiots  without  attention  absolutely  ineducable,  leading  a  vegetative 
existence ;  others,  again,  exhibiting  both  spontaneous  and  voluntary 
attention,  but  in  flashes,  as  it  were,  of  brief  duration  and  faint  in  na- 
ture ;  and  still  others  more  or  less  capable  of  prolonged  and  habitual 
attention.  It  is  only  in  the  last-named  group  of  individuals  that  edu- 
cation is  to  any  considerable  degree  feasible.  The  education  appeals 
in  some  to  the  simplest  sentiments  only  (such  as  curiosity,  selfish- 
ness, the  desire  of  rew^ard),  in  others  attention  is  aroused  by  appeals  to 
a  higher  affective  order  (such  as  interest,  ambition,  and  emulation),  and 
in  still  others  attention  may  be  aroused  and  sustained  by  habit. 

Since  the  power  of  attention  directed  to  external  events  is  so  feebly 
developed  in  idiots,  it  is  not  surprising  that  attention  to  internal  happen- 
ings, or  reflection,  should  be  totally  absent  in  all  grades  of  idiocy. 

Ribot  regards  voluntary  attention  as  habitual  and  disciplined  spon- 
taneous attention,  as  an  adaptation  to  the  conditions  of  a  higher  social 
life,  as  a  sociological  phenomenon.  When  the  development  of  voluntary 
attention  is  rudimentary,  and  the  resulting  intellectual  defect  is  marked, 
as  in  the  lower  grades  of  idiocy,  there  are  no  serious  consequences  from 
the  sociological  point  of  view.  Sollier  calls  the  idiot  eifra-social,  and 
makes  the  imbecile  quite  distinct  as  an^i-social,  claiming  that  in  the 
latter  there  is  an  undefined  amount  of  voluntary  attention,  combined 
with  a  relative,  though  perverted,  intelligence,  which  two  factors  render 
him  often  a  dangerous  member  of  society.  He  speaks  of  the  instability 
of  the  attention  of  the  imbecile.  At  one  moment  it  may  be  faint,  at 
another  intense  as  in  normal  man.  He  passes  from  one  subject  to  an- 
other with  the  greatest  ease,  a  characteristic  which  may  even  be  observed 
in  his  infancy.  Serious  matters  must  be  continually  repeated  to  him  to 
make  him  understand.  He  grasps  the  first  part  of  a  sentence,  and 
forms  his  ideas  from  that,  without  waiting  for  the  sentence  to  be  com- 
pleted. He  frequently  interrupts,  and  there  is  no  time  to  answer  one 
question  before  another  is  put.  Sollier  further  goes  on  to  say  that  this 
instability  of  the  attention  for  external  objects  or  ideas  is  seen  also  in 
the  acts  of  the  imbecile,  who  is  incapable  of  intelligent  labor,  and  accom- 
plishes his  tasks,  when  uniform,  by  a  certain  kind  of  automatism,  with- 
out due  appreciation  of  the  object  of  his  work.  When  the  object  is 
understood,  the  imbecile  believes  he  can  attain  it  immediately,  and, 
seeing  the  first  step  only,  is  prevented  by  failure  of  attention  from  properly 
completing  the  work  or  doing  it  at  all.  He  seems  to  forget  that  he  has 
begun,  and  as  a  consequence,  unless  watched,  may  spoil  whatever  he  at- 
tempts. Other  imbeciles  refuse  to  work,  but  make  themselves  very  busy 
and  important  in  watching  and   supervising  the  occupations  of  others. 


860  MENTAL   DISEASES. 

Sollier  calls  them  vagabonds.  They  wander  away  not  knowing  where, 
marching  straight  before  them,  with  indiflPerence  to  the  welfare  of  the 
friends  or  relatives  they  desert ;  traveling  by  night  and  hiding  by  day ; 
undisciplined,  indolent,  and  mischievous. 

This  attempt  to  separate  idiots  and  imbeciles  into  two  distinct  classes 
of  extrasocial  and  antisocial  is,  to  my  mind,  not  justifiable.  Sollier 
has  here  described  a  certain  class  of  imbeciles  only,  and  the  description 
is  very  true  to  nature,  but  it  is  only  a  group  which  does  not  merit  an 
especial  classification.  As  regards  attention,  we  should  still  hold  to  the 
terms  idiocy,  imbecility,  and  feeble-mindedness,  as  representing  degrees 
of  lack  of  attention,  from  complete  or  almost  complete  absence  to  mere 
diminution  of  the  faculty.  The  adult  imbecile,  in  the  middle  grade, 
would  have  the  varying  and  imperfect  attention  of  a  backward  child, 
and  his  ideas,  speech,  and  conduct  would  vary  with  his  temperament, 
with  his  docility  or  perversity  ;  in  short,  with  the  innate  diiferences  of 
character  and  individuality,  which  may  be  as  manifest  in  imbeciles  as 
in  normal  children.  Imbeciles  may  and  do  become  vagabonds,  un- 
certain, mischievous,  indolent,  antisocial ;  but  they  may,  on  the  other 
hand,  be  good-natured,  trusty,  docile,  industrious.  Many  of  them,  too, 
may  show  special  aptitudes  in  certain  directions.  As  to  education,  the 
difficulties  are  that  in  some  it  is  hard  to  attract  the  attention,  and  in 
others  to  maintain  it. 

Reflection. — The  internal  form  of  attention  (reflection  of  Ribot), 
in  which  images  and  ideas  constitute  the  subject-matter,  is  quite  defi- 
cient in  the  lower  grades  of  idiocy,  but  is  jjresent  in  imbecility  and 
feeble-mindedness  in  varying  degrees.  It  is  never  perfectly  developed, 
as  in  normal  man. 

Preoccupation. — This  is  absent  in  profound  idiocy  and  feeble  in 
the  higher  grades.  A  small  proportion  of  imbeciles  are  capable  of 
preoccupation,  but  of  an  indefinite  nature,  and  sometimes  taking  on  the 
character  of  a  fixed  idea.  Often  their  interest  is  not  aroused  so  much 
by  what  benefits  and  interests  mankind  in  general  as  by  bad  actions, 
criminal  or  egoistic  sentiments  that  attract  their  attention  and  arouse 
reflection  and  preoccupation  which  may  result  in  felony  or  crime. 
Many  are  too  selfish  to  care  for  the  troubles  of  others,  and  too  stupid 
to  have  preoccupations  purely  intellectual. 

Instincts. — The  instincts  in  idiocy  are  generally  defective.  The 
defect  may  be  imperfection  of  development  or  an  actual  derangement 
or  perversion.  The  instinct  of  hunger  is  present  in  almost  all  grades 
of  idiocy,  and  is  so  little  inhibited  that  it  is  often  pushed  to  the  extent 
of  gluttony.  The  instinct  of  self-preservation  is  impaired  in  nearly 
all,  absent  in  profound  idiocy,  ungoverned  by  proper  judgment  in  the 
milder  forms.  In  some  there  is  no  sense  of  fear,  and  self-injury  is 
possible.  In  others  there  is  a  comprehension  of  danger  and  an  avoid- 
ance of  it,  or  possibly  an  overweening  egoism  which  may  lead  to  a 
belief  in  their  power  to  overcome  it.  Suicide  occurs  in  imbeciles  and 
feeble-minded,  sometimes  without  determinable  cause,  sometimes  as  a 
result  of  morbid  impulse. 

Sleep  is  good  among  all  classes  of  idiots,  while  in  the  lower  grades 


IDIOCY.  861 

it  may  be  both  profound  and  excessive.     Wliether  they  dream  or  not 
depends  solely  upon  the  degree  of  mental  development. 

The  desire  and  need  of  voluntary  muscular  movement  varies  with 
the  scale  of  intelligence,  being  absent  in  the  profounder  degrees  of 
idiocy,  and  approximating  the  normal  the  higher  the  psychic  develop- 
ment. The  automatic  and  impulsive  movements  in  some  may  represent 
a  fulfilment  of  the  normal  need,  and  the  extreme  restlessness  of  others 
is  surely  a  perversion  of  the  natural  desire. 

The  sexual  instinct  may  be  absent,  impaired,  exaggerated,  or  per- 
verted. It  is  seldom  normal.  Idiots  of  all  degrees  present  many  de- 
generative stigmata  as  regards  the  genital  organs,  more  numerous  in 
direct  proportion  to  the  mental  impairment.  Among  these  anomalies 
are  :  cryptorchismus,  unilateral  or  bilateral  microrchidia,  spurious  her- 
maphroditism, insuflticient  development  of  the  entire  genital  apparatus, 
hypospadias  or  epispadias  ;  defect,  torsion,  or  great  volume  of  the 
prepuce ;  median  lissure  of  the  scrotum,  imperforate  meatus,  abnor- 
mally large  or  small  labia,  excessive  development  of  the  clitoris, 
hypertrophied  labia  minora,  pigmentation  of  the  labia  minora,  imper- 
forate vulva,  atresia  of  or  double  vagina,  and  uterus  bicornis. 
Puberty  is  often  retarded,  but  occasionally  is  early  ;  often  it  is  normal. 
Masturbation  is  exceedingly  common  among  all  classes  of  idiots  of  both 
sexes.  In  the  profound  degrees  it  is  automatic  ;  in  the  higher  it  is 
purposive.  Onanism  a  deux  and  sodomy  are  frequently  discovered 
among  imbeciles  and  feeble-minded,  and  sexual  psychopathies  of  the 
most  shocking  nature  are  not  uncommonly  manifested  in  some  because 
of  the  combination  of  the  strong  sexual  instinct  and  absence  of  moral 
sensibility. 

The  instinct  of  imitation,  which  is  a  low  form  of  instinct,  and  strong 
in  children  and  many  lower  animals,  is  one  to  which  idiots  are  very 
susceptible.  It  is  usually  a  purely  instinctive  or  passive  imitation, 
seldom  an  intellectual  or  active  imitation.  Its  intensity  depends  much, 
however,  upon  the  scale  of  intelligence  to  which  the  idiot  rises.  It  is 
very  apt  to  be  shown  in  the  form  which  is  concerned  with  moral  conta- 
gion ;  so  that  the  acts  and  language  of  the  vicious,  mischievous,  coarse, 
and  vulgar  are  most  willingly  imitated.  Simulation  is  very  common 
among  the  more  intelligent  classes  of  idiots. 

Special  Aptitudes. — In  the  so-called  idiots  savants  we  note  the  de- 
velopment of  special  aptitudes,  occasionally  remarkable,  more  often 
only  note^vorthy  in  contrast  to  the  general  mental  vacuity.  These  apti- 
tudes are  usually  in  the  direction  of  music,  mathematics,  the  mechanical 
arts,  building,  wood-carving,  drawing,  painting,  memory  for  facts  or 
dates,  playing  games,  and  of  a  low  order  of  wit  or  drollery.  The  occa- 
sional preeminence  of  some  particular  faculty,  where  all  other  traits  are 
defective,  would  almost  lead  one  to  believe  in  a  heterotopia  of  gray 
matter  in  some  special  locality.  Music,  the  most  sensual  of  the  arts, 
seems  to  appeal  especially  to  this  class  of  individuals.  Often  the 
rhythm  of  it  seems  to  influence  the  rhythm  of  their  automatic  move- 
ments, or  it  soothes  their  restlessness  or  stops  their  cries.  Sometimes 
unteachable  idiots  are  able  to  retain,  recall,  and  hum  a  moderately  diffi- 


862  3IENTAL    DISEASES. 

cult  tune,  while  higher  grades  may  learn  to  play  instruments  by  ear, 
though  not  by  note.  Xext  to  aptitude  for  music,  that  for  mental  arith- 
metic is  often  surprising.  There  are  also  occasional  instances  of  the 
other  talents  just  mentioned,  and  doubtless  the  court  fools  of  the  past, 
with  their  mischievous  pranks  and  quaint  remarks,  were  recruited  to  a 
great  extent  from  the  imbecile  class. 

Play. — There  is  a  lack  in  all  classes  of  idiots,  and  in  direct  propor- 
tion to  the  degree  of  mental  defect,  of  that  "  superfluous  activity  which 
is  expended  in  the  form  of  play."  The  activity  and  attention  of  normal 
children  are  mainly  developed  through  play.  This  avenue  of  education 
is,  unfortunately  to  a  considerable  degree,  closed  in  idiocy.  The  lower 
grades,  if  they  manifest  a  tendency  to  play  at  all,  do  so  in  a  rudimentary 
and  solitary  way,  and  in  adolescence  still  cling  to  the  simple  games  of 
infancy.  With  others,  higher  in  the  scale  of  intelligence,  there  is  still 
defect  of  the  play  instinct,  and  a  proclivity  often  to  prefer  games  in 
which  noisiness,  destructiveness,  and  other  evidence  of  rather  brutal 
traits  are  paramount.  Sometimes  these  games  are  carried  on  good- 
naturedly  ;  at  others,  selfishness,  irritability,  quarrelsomeness,  and  a 
more  or  less  ungovernable  nature  are  evinced. 

Civility  and  politeness  may  be  taught  to  many,  but  naturally  with 
difficulty  to  the  lower  grades  and  to  such  individuals  of  the  higher  as 
are  hard  to  train  in  other  directions,  because  of  innate  vices  of  tempera- 
ment and  character. 

Destructiveness,  a  propensity  even  in  normal  children  at  an  early 
age,  is  an  especial  attribute  of  all  classes  of  idiots.  In  those  of  low 
degree  it  is  automatic  and  possibly  a  rudimentary  form  of  superfluous 
activity  (play),  but  in  some  individuals  of  the  superior  grades  there 
seems,  at  times,  to  be  a  vicious  satisfaction  in  inflicting  damage  or 
injury,  which  may  even  lead  to  the  manifestation  of  homicidal  proclivi- 
ties or  a  tendency  to  arson  (pyromania).  Self-mutilation  or  injury  may 
be  a  result  of  the  love  of  destruction  in  the  pro  founder  degrees  of  idiocy. 

Sentiments. — In  the  lowest  forms  of  idiocy  the  sentiments  and 
sensations  are  rudimentary,  or  may  be  altogether  absent.  As  a  rule,  one 
may  discover  various  degrees  of  pleasure  or  pain,  afl'ection,  pity,  fear, 
social  proclivities,  love  of  property,  regard  for  rights  and  duty,  obedi- 
ence, shame,  esthetic  feelings,  curiosity,  and  the  like. 

Pleasure  and  pain  are  indefinite  or  absent  sensations  in  idiots,  felt 
to  a  greater  extent  by  imbeciles,  and  well  marked  in  the  feeble-minded. 
Joy,  sadness,  and  anger  are  usually  aroused  by  physical  sensations. 
The  self-mutilation  of  some  idiots  points  to  an  absence  of  the  pain 
sense,  and  idiot  ^vomen  have  been  known  to  bear  children  without  ex- 
periencing the  pains  of  labor.  Idiots  often  cry  out  suddenly,  burst  out 
laughing,  or  throw  themselves  about,  which  is  probably  explicable  by 
variations  of  perception  in  the  somesthetic  sense.  Moral  pain  or 
remorse,  usually  wanting,  is  sometimes  developed  to  a  slight  extent.  It 
is  not  often  that  these  defectives  weep,  and  if  they  cry,  it  is  bnt  for  some 
momentary  pain  or  deprivation.  They  live  in  the  present  only,  and  do 
not  concern  themselves  about  the  past  or  future.  In  the  higher  grades 
it  is  physical,  seldom  moral,  pain  that  is  taken  note  of.     Pleasure  is 


IDIOCY.  863 

as  little  expei'icncecl  as  ])ain  in  the  lower  degrees,  and  laughter  is  as 
infrequent  us  crying.  Pleasure  is  expressed  by  imbeciles  and  the 
feeble-minded  by  laughter,  clapping  the  hands,  or  cries,  though 
laughter,  even  with  these,  is  uncommon.  There  are,  however,  certain 
imbeciles  that  always  have  a  good-natured  smile,  and  laugh  readily  and 
excessively  over  nothing.  Frequently  the  laughter  is  a  true  automatic 
movement,  as  infantile  spontaneous  motor  expression. 

Afection  is  a  sentiment  not  uncommon  in  idiocy,  though  it  varies 
with  the  degree,  being  often  rudimentary,  vague,  indefinite,  and  proba- 
bly inspired  rather  by  the  ministration  to  his  wants  than  by  the  care- 
taker. It  is  found  that  nearly  all  forms,  except  the  lowest,  appreciate 
kindness  and  patience,  and  are  repulsed  and  made  unmanageable  by 
brusqueness  or  cruelty.  With  certain  imbeciles  and  feeble-minded, 
wdiere  the  moral  sense  is  not  too  much  obtunded,  true  affection  for  indi- 
viduals is  manifested  ;  but  when  the  moral  sense  is  deficient,  affection 
is  elementary  or  absolutely  wanting,  so  that  kindness  is  either  unappre- 
ciated or  at  once  forgotten. 

There  are  variations  of  the  same  nature  in  love  for  the  family  and  in 
friendship.  Absent  in  the  simplest  idiots,  it  may  be  shown  in  greater 
or  less  degree  in  the  higher  grades.  In  some  it  is  unstable,  changeable, 
and  influenced  much  by  the  selfishness  of  the  individual.  In  others, 
again,  there  is  a  perversion  of  family  love,  so  that  they  are  hateful  and 
disagreeable  to  their  parents  or  brethren.  It  is  much  the  same  with 
friendship.  Often  mild  types  of  idiocy  form  in  asylums  friendships  for 
one  another,  though  they  are  too  often  apt  to  be  associations  of  a  sexual 
nature  or  for  the  purpose  of  combining  together  for  mischievous  pur- 
poses. A  true  solidarity  of  interests  or  social  proclivity  is  seldom 
observed.  Maltreatment  of  animals  by  idiots  is  usually  due  to 
ignorance,  but  there  are  moral  imbeciles  who  perpetrate  cruelties  on 
animals  as  well  as  human  beings  from  pure  perversity  and  love  of  in- 
flicting pain.  The  passion  of  love,  when  it  exists,  which  is  extremely 
rare,  is  founded  altogether  upon  a  physiological  basis.  Jealousy  is 
sometimes,  though  infrequently,  observed. 

Pity  is  quite  unknown  in  all  degrees  of  idiocy.  Some  are  amused  or 
curious  and  some  alarmed  at  the  sufferings  of  others. 

Fear  is  a  common  sentiment  in  all  types  of  cases,  more  common  than 
in  normal  persons,  because  of  the  want  of  understanding.  Often  the 
simplest  occurrences  inspire  fear.  On  the  other  hand,  when  much 
excited,  there  are  types  that  exhibit  no  fear  at  all. 

Courage  is  wanting  in  all  classes  of  idiocy.  Auger  is  apt  to  manifest 
itself  in  all  degrees  and  in  every  age.  It  is  apt  to  be  both  causeless 
and  paroxysmal,  and  to  lead  to  the  infliction  of  injuries  upon  the  indi- 
vidual himself,  upon  inanimate  things,  or  upon  persons  in  the  vicinity. 
The  ungovernable  rage  is  usually  increased  by  efforts  to  restrain  the 
patient. 

Acquisitiveness  is  shown  in  imbeciles  and  the  feeble-minded  by  a 
propensity  for  the  collection  of  all  sorts  of  useless  objects  and  trifles, 
much  the  same  as  in  cases  of  chronic  mania.  There  is  often  a  marked 
tendency  to  steal,  sometimes  deliberately,  and  at  other  times  without 


864  3IENTAL   DISEASES. 

motive,  merely  to  gratify  the  desire  of  possession.  The  lower  orders 
appropriate  evervtliing  coming  in  their  way,  having  no  regard  for  the 
property  of  others.  Many  can  be  taught  acquisition  as  a  reward  for 
labor,  and,  on  the  other  hand,  there  are  some  who  can  be  made  to  work 
onlv  through  fear,  having,  as  they  do,  an  innate  antij^athy  to  occupation 
of  any  kind. 

With  respect  to  rights  and  duty,  the  perceptions  of  the  idiot  vary  with 
the  deo-ree  of  mental  and  moral  defect.  In  some  even  inferior  idiots 
these  perceptions  may  be  present,  while  with  some  the  rights  of  others 
are  never  respected,  though  to  their  own  they  may  cling  tenaciously, 
and  the  feeling  of  duty  may  never  be  instilled  into  them,  because  of 
more  or  less  moral  perversion. 

Obedience  and  respect  for  authority  vary,  too,  with  the  amount  of  intel- 
ligence and  the  degree  of  moral  impairment.  Quite  simple  idiots  may 
quickly  respond  to  the  word  of  command.  On  the  other  hand,  some  of 
the  most  intelligent  may  perversely  resist  all  attempts  at  discipline. 
Compensation  and  punishment  affect  them  variously.  Reward  in  object- 
ive shape  or  in  the  form  of  praise  is  seldom  appreciated  by  inferior 
grades,  and  often  unduly  by  the  higher.  Punishment,  objective  or  in 
the  form  of  blame,  is  useless  for  the  simpler  degrees  of  idiocy,  where 
acts  are  unintentional,  and  in  some  of  the  more  intelligent  excites  antip- 
athy, an  unreasonable  sense  of  injustice,  and  often  causes  them  to  harbor 
a  vengeful  feeling. 

A  true  religious  sentiment  is  quite  unknown  in  any  form  of  idiocy. 
This  is  true  also  of  the  feeling  of  shame.  The  only  esthetic  sentiment 
found  in  these  defectives  is  the  love  of  music  or  rhythm,  which  is  quite 
general  among  all  classes,  though  not  perhaps  so  noteworthy  as  it  has 
sometimes  been  stated  to  be.  Occasionally  we  meet  with  cases  having 
unusual  musical  aptitude.  It  is  rather  a  rhythmic  noise  which  appeals 
to  most  of  them,  such  as  beating  of  a  drum,  hammering,  the  grinding  of 
an  organ  (even  if  out  of  tune  and  discordant).  They  have  no  sense  of 
beauty,  but  things  bizarre,  grotesque,  glittering,  and  colossal  attract 
their  attention.  Curiosity  and  astonishment  are  aroused  more  readily 
through  the  sense  of  sight  than  that  of  hearing,  and  are  often  more  easily 
roused  in  some  of  the  lower  grades  than  in  the  higher  types  of  idiocy. 

All  classes  evince  a  marked  credulity,  and  often  it  is  difficult  or 
impossible  to  eradicate  an  idea  once  established.  Fairy  stories  are 
especially  pleasing  to  many  of  them,  just  as  they  are  to  children. 

Veracity  is  a  virtue  which  is  uncommon  among  idiots.  Many  imbe- 
ciles are  particularly  apt  to  be  untruthful  and  deceitful  with  regard  to 
their  faults,  doings,  physical  condition,  things  found  in  their  possession, 
and  the  like.  Naturally,  the  simple  idiot,  owing  to  his  feebleness  of 
invention,  if  given  to  lying,  limits  his  untruths  to  the  simplest  matters, 
such  as  denials  of  accusations  brought  against  him,  etc. 

Physiog-nomy  and  Expression  and  Character. — Idiots  all  show 
deficiency  in  their  general  appearance.  There  is  always  something 
ungracious,  uncouth,  ugly  in  their  figures,  faces,  attitudes,  or  move- 
ments. Very  common  among  them  are  misshapen  or  asymmetrical 
heads,   dwarfishness,   lack    of  proportion    of  the   limbs,  stooping    and 


IDIOCY.  865 

slovenly  postures,  deformities  of  the  hands  or  feet,  and  awkward  and 
wobbling  gait.  The  expression  of  the  face  varies  from  complete  apathy 
and  absence  of  intelligence  to  a  considerable  play  of  features  of  a  low 
order,  such  as  constant  laughing,  making  faces,  leering,  or  scowling. 
Besides  the  absence  of  those  facial  traits  which  are  made  on  the  face  hj 
the  mind,  the  ugliness  is  generally  added  to  by  asymmetry,  disproportion 
or  deformity  of  the  features.  The  eyes  may  be  too  close  together  or 
too  far  apart,  or  deformed  by  disease  of  the  iris,  cornea,  or  lids,  or 
by  squint.  The  nose  deviates  or  is  malformed,  the  ears  are  unshapely 
and  unequal,  the  mouth  half  open,  the  teeth  diseased  and  neglected  ;  the 
chin  deviated,  prominent,  or  retreating  ;  the  forehead  low  and  bulging  or 
inclined.  Microcephalus,  hydrocephalus,  and  cretinism  give  their  own 
ugly  individuality  too  well  known  to  need  description  here.  Where  a 
head  is  shapely  and  a  face  has  any  vestige  of  pleasing  lines,  it  is  gener- 
ally fair  to  infer  that  the  mental  state  is  due  to  deprivation  of  one  or 
more  senses,  or  to  the  insanity  of  childhood. 

As  to  character,  this,  too,  varies  with  the  amount  of  mental  defect, 
and  is  difficult  to  analyze.  In  profound  idiots  there  are  often  sudden 
accesses  of  excitement  without  apparent  cause.  In  higher  types  the 
basis  of  character  is  inconstancy,  weakness  of  will,  and  blunting  of 
the  sensibilities,  their  humor  depending  largely  upon  their  environment, 
showing  an  appreciation  of  kindness  and  resentment  of  ill-usage. 
Some  are  clever  and  good-natured  and  funny,  often  making  sharp  re- 
marks or  doing  amusing  things,  and  at  one  time  such  eases  were  in 
great  demand  as  court  or  family  fools.  History  shows  there  were  two 
kinds  of  fools  made  use  of  by  royal  and  noble  families — the  true  or 
natural  fools  (idiots  or  imbeciles),  who  were  the  first  to  create  the  pro- 
fession, and  their  crafty  imitators,  the  artificial  fools,  who  made  of  it  a 
profitable  calling. 

I  should  differ  entirely  from  Sollier  in  his  somewhat  extraordinary 
distinction  of  imbeciles  from  idiots.  He  really  selects  one  type  of 
imbecile,  w^hile  we  know  that  there  are  many,  and  erects  this  single 
type  into  a  great  class  which  he  everywhere  distinguishes  in  his  book 
as  the  imbecile.  To  him  the  imbecile  is  egotistical,  boastful,  vicious, 
careless,  dangerous,  a  glutton,  a  vagabond,  a  mischief-maker,  a  sexual 
pervert,  unstable,  lazy,  abusive,  obscene,  forgetful  of  kindness,  venge- 
ful, shameless,  and  altogether  antisocial. 

Language. — The  primitive  physical  basis  of  language  in  the  nor- 
mal human  infant  is  the  auditory  tract  and  the  word-hearing  center. 
It  is  essentially  receptive.  Then  develops  the  word-comprehending 
center.  After  this  the  motor  speech  center  is  developed  and  associated 
with  the  ])rimitive  physical  basis,  thus  establishing  the  emissive  faculty. 
This  rudimentary  linguistic  apparatus  is  variously  defective  in  idiots. 
A  defect  in  the  emissive  power  is  not  so  serious,  as  regards  intelligence, 
as  one  in  the  receptive  ;  for  idiots  of  considerable  intelligence  may  not 
be  able  to  talk  at  all,  while  others  very  inferior  may  speak  with  readi- 
ness. Any  part  of  this  original  physical  basis  of  language  may  be 
affected,  and  the  result  to  the  defective  individual  will  depend  much 
upon  what  function  is  lost.     The  auditory  apparatus  may  be  imperfect. 


866  MENTAL   DISEASES. 

The  word-hearing  center  may  not  act.  The  word-comprehending  cen- 
ter may  be  undeveloped.  In  such  instances  the  intellect  will  suffer 
severely.  Unlike  the  normal  child,  which  comprehends  many  things 
said  to  it  as  early  as  nine  months  of  age,  in  cases  of  this  kind  compre- 
hension will  develop  very  late,  or  perhaps  never ;  yet  occasionally  with 
the  development  of  the  emissive  power  (without  the  word-comprehend- 
ing center)  words  may  be  heard,  learned,  and  repeated,  constituting  an 
echolalia — speech  without  idea.  Supposing  the  emissive  apparatus  alone 
to  suffer,  we  have  hearing  and  comprehension  and  the  development  of 
the  mind,  yet  without  the  power  of  speech. 

Like  an  animal,  the  idiot  may  be  intelligent,  but  speechless.  The 
development  of  language  and  intelligence  is  not  parallel.  Sollier  dis- 
tinguishes two  kinds  of  mutism  in  idiots — a  motor  and  a  sensory  aphasia. 
In  the  first  he  can  not  talk,  though  he  understands ;  in  the  second, 
nothing  which  is  said  is  understood.  Language  is  very  late  in  develop- 
ment in  idiots.  The  crowing  of  the  normal  infant  is  not  often  observed, 
but  meaningless  and  monotonous  cries  take  its  place.  The  laryngeal 
sounds  are  earliest  and  best  enunciated,  the  lingual  and  labial  latest  and 
least  distinctly.  Wildermuth  classifies  the  dysarthrias  and  lalopathies 
of  idiots  into  two  groups  : 

1.  Where  the  disturbance  of  speech  is  the  direct  expression  of  the 
intellectual  density.  They  lack  ideas,  and  consequently  have  not  the 
words  for  the  expression  of  them.  In  the  lowest  degree,  the  idiot  is  a 
vegetative  automaton ;  in  a  less  profound  degree,  he  is  like  a  child  of 
two  or  three  years,  with  imperfections  of  grammar  and  syntax. 

2.  When  the  disturbance  of  speech  is  a  complication  of  idiocy,  and 
is  mechanical  rather  than  intellectual,  Wildermuth  has  rarely  found 
stumbling  speech  in  the  idiot,  and  never  stammering.  These  defects 
are  sometimes  found  in  imbeciles,  who,  moreover,  talk  a  great  deal  and 
without  definite  object ;  who  have  onomatomania,  and  who  are  subject 
to  transitory  attacks  of  excessive  and  maniacal  loquacity. 

Considerable  loquacity  is  occasionally  observed  in  cases  of  acquired 
idiocy. 

Next  to  hearing,  the  visual  tract  and  the  word-seeing  and  compre- 
hending centers  form  a  great  receptive  avenue  for  language  and  ideas. 
Reading  will  be  impossible  to  such  idiots  as  have  defect  of  the  visual 
apparatus  or  these  centers,  and  the  degree  of  acquisition  of  this  power 
will  depend  upon  the  degree  of  defect.  There  are  idiots  who  learn 
merely  the  letters,  others  who  acquire  monosyllables,  and  still  others 
who  can  be  taught  to  read  laboriously.  Sometimes  such  reading  is 
purely  automatic,  without  actual  comprehension.  The  higher  the  grade 
of  idiocy,  imbecility,  or  feeble-mi ndedness,  the  greater  the  develop- 
ment of  this  faculty,  though  few  of  either  class  ever  attain  to  perfectly 
correct  reading. 

The  writing  center  and  its  association  tracts  are  the  latest  portions  of 
the  linguistic  cerebral  basis  to  be  established  in  normal  cases,  and  in 
the  idiot  are  apt  to  be  the  least  well-constituted.  In  addition  to  its  in- 
tellectual side,  there  is  a  complicated  muscular  co5rdination  required  in 
writing  which  also  renders  it  more  difficult  for  defectives  of  this  kind. 


IDIOCY.  867 

They  may  be  tauglit  to  reproduce  letters,  but  the  characters  are  mean- 
ingless to  them.  A  few  write  quite  legibly,  though  seldom  or  never 
Avell.  As  Sollier  says,  their  writing  is  in  reality  drawing,  and  they 
like  to  copy  printed  letters,  curved  lines,  and  so  on.  There  is  a  certain 
tendency  to  write  with  the  left  hand  and  to  write  from  right  to  left. 

In  (IrdirhHj,  such  as  learn  at  all  copy  slowly  and  uncertainly,  with- 
out perspective,  and  never  draw  without  a  copy  or  model  ;  or  they  do 
the  work  impatiently,  and,  if  given  free  rein,  indulge  in  curious  and 
fantastic  scrawls,  such  as  are  figured  in  the  works  of  Sollier,  Bourne- 
ville,  and  others. 

Intelligence. — Since  intelligence  depends  upon  the  acquisition,  con- 
servation, association,  and  production  of  ideas,  and  these  upon  the  con- 
dition of  the  sensory  organs  and  centers  and  language  centers,  it  is 
mainly  in  intelligence  that  the  idiot  deviates  from  normal  man.  The 
deviation  varies  much  in  degree,  from  almost  total  absence  to  a  condi- 
tion nearly  approaching  the  normal.  The  idiot  has  fewer  ideas  than 
the  imbecile,  and  the  imbecile  fewer  than  the  feeble-minded.  All 
classes  acc^uire  ideas  primarily  in  the  same  way  as  the  normal  infant — 
through  the  senses  ;  but  while  the  normal  child  later  on  acquires  ideas 
chiefly  by  means  of  language  and  imitation,  the  defective  continues  to 
make  use  mainly  of  the  senses  for  this  purpose,  owing  to  the  faulty 
development  of  the  language  centers.  Preyer  shows  that  questions 
and  names  are  understood  before  the  normal  child  can  speak  (nine 
months),  Avhile  idiots,  many  years  of  age,  may  have  an  intelligent  idea 
of  the  use  of  things,  yet  not  know  their  names  when  heard,  and  be 
unable  to  speak  them. 

As  regards  concrete  ideas,  such  as  the  different  qualities  of  matter, 
it  is  noticeable  that  the  idiot  appreciates  colors  (particularly  red),  rec- 
ognizes surfaces,  avoids  obstacles,  and  notices  the  difference  between 
round  and  square,  Avhile  distances  and  space  are  not  comprehended.  As 
Sollier  correctly  says,  imitation,  which  is  a  source  of  ideas  for  infants, 
does  not  develop  the  intelligence  of  the  idiot ;  for  to  him  it  does  not 
furnish  an  idea,  but  creates  a  mechanism.  In  the  superior  grades  of 
idiocy  imitation  creates  an  idea  which  is  assimilated  by  the  intelligence  ; 
but  as  the  intelligence  can  not  retain  it,  the  result  is  the  same  as  though 
it  had  not  been  assimilated.  Still,  it  is  not  just  to  infer,  from  lack  of  . 
intellectual  expression,  that  there  is  complete  intellectual  inactivity^. 
That  ideas  may  exist  in  a  brain  apparently  inactive  is  shown  by  the 
phenomenon  of  intellectual  manifestation  induced  in  idiots  by  severe 
pain,  disease,  etc.  In  other  words,  the  intellectual  receptivity  of  idiots 
may  be  greater  than  supposed,  until  some  irritation  occurs  strong 
enough  to  show  that  the  preceding  stimuli  have  left  their  effects  on  the 
brain  centers.  Thus,  Griesinger  reports  the  case  of  an  idiot  who  could 
only  speak  a  few  words  until  he  contracted  hydrophobia,  when  he  began 
to  talk  of  events  which  had  taken  place  several  years  before. 

As  regards  the  conservation  of  ideas,  we  must  remember,  says  Sollier, 
that  memory  is  hereditary,  organic,  or  acquired.  Hereditary  memory 
is  extremely  complex  and  difficult  of  explanation,  but  it  apparently 
occurs  in  idiots.     Organic  memor}^,  or  unconscious  memorv', — viz.,  of 


868  3IEXTAL   DISEASES. 

associated  movements,  such  as  walking, — although  sometimes  completely 
absent  in  idiots,  owing  to  defective  nerve  centers  and  lack  of  attention^ 
is,  nevertheless,  better  developed  than  either  of  the  two  other  varieties. 
For  acquired  memory,  attention  is  still  more  a  shie  qua  non,  and  conse- 
quently this  is  the  least  developed  form  of  memory  in  idiots.  Memorj" 
in  an  idiot  develops  slowly ;  at  first  its  existence  is  shown  only  by  the 
stimulus  of  some  violent  excitement.  This  indicates  that  memory  exists 
in  so  far  as  the  conservation  of  the  image  is  concerned,  but  not  enough  for 
its  reproduction  under  ordinary  circumstances.  In  a  higher  degree  of 
the  development  of  memory,  the  idiot  can  recall  the  memory  picture  by 
seeing  again  the  original  object  (memory  for  food,  memory  for  places). 
Local  memory,  which  does  not  act  by  satisfaction  of  a  natural  need,  is 
only  found  in  educable  idiots  (remembers  his  own  bed,  etc.).  This 
memory  is  fixed  by  repetition  of  the  sensation,  and  has  not  an  emotional 
basis.  These  varieties  of  memory  are  simple,  and  do  not  necessitate 
language.  As  soon  as  language  exists,  a  much  wider  field  opens  for  the 
memory. 

In  simple  idiots  there  is  no  association  of  ideas.  The  primitive 
forms  of  association,  such  as  fear  and  the  hope  of  reward,  awaken  no 
associated  ideas  in  them,  and  even  in  the  superior  ty])es.  of  idiocy  there 
is  no  great  development  of  this  form  of  memory. 

It  is  a  curious  and  inexplicable  phenomenon  that  m  certain  cases  of 
idiocy  there  may  exist  particular,  specialized  memories,  such  as  for 
musical  airs,  dates,  and  numbers,  although  memory,  in  its  usual  and 
general  sense,  may  be  deficient.  Indeed,  as  a  rule,  the  memory  is  feeble 
in  all  classes  of  idiocy,  and  even  in  cases  where  the  memory  is  fairly 
well  constituted  it  is  ordinarily  mechanical,  useless  to  the  possessor, 
automatic. 

Xaturally,  as  abstract  ideas  result  from  reason,  comparison,  and 
judgment,  such  ideas  are  absent  in  the  lowest  order  of  idiocy.  Pro- 
found idiots  have  no  idea  of  differences  of  persons  or  things.  Higher 
idiots  may  be  able  to  appreciate  superficial  resemblances  and  differences, 
especially  of  color  and  form,  but  the  discernment  is  so  faulty  that 
incorrect  inferences  frequently  result. 

Superior  idiots  appreciate  resemblances  more  readily  than  differences. 
Simple  generalizations  may  be  possible,  however,  to  all  classes.  In  the 
lower  types  such  generalizations  occur  only  after  long  instruction,  and, 
once  this  power  is  acquired,  they  may  be  fairly  correct,  but  in  many  of 
the  higher  they  are  hasty  and  often  faulty.  In  educaljle  idiots,  even 
those  who  can  not  talk,  there  is  an  appreciation  of  number,  and  they 
may  be  taught  to  count.  Addition  is  more  easily  learned  than  subtrac- 
tion, and  multiplication  can  only  be  learned  by  those  with  fairly 
developed  memories.  Division  can  rarely  be  taught  them,  and  neither 
idiots  nor  imbeciles  can  understand  problems.  The  superior  orders  of 
idiocy  can  count  automatically,  but  rarely  are  able  to  do  so  with  proper 
understanding.  They  can  say  two  and  two  make  four,  four  and  four 
make  eight ;  but  ask  them  how  many  are  four  and  three  and  they  are 
at  sea.  To  count  Ijeyond  ten,  the  number  of  the  fingers,  is  rarely 
learned.     But  there  are  phenomenal  instances  where  the  mathematical 


IDIOCY.  869 

faculty  is  remarkably  developed,  as  in  the  cases  of  the  so-called 
"  calcLdatiug  boys/'  some  of  whom,  it  is  true,  are  normal  in  other 
respects,  but  many  of  whom  are  mentally  defective,  belonging  to  the 
cateo-orv  of  idiots  or  imbeciles. 

The  idea  of  time,  past  and  future,  has  seldom  a  place  in  the  l)rain 
of  the  idiot. 

Ideas  in  the  idiot  are  too  feeble  to  be  lixed  ideas,  and  while  the 
higher  types  are  sometimes  subject  to  morbid  impulses,  there  is  not  a 
true  tixed  idea,  with  consciousness  and  pain.  AVith  them  such  ideas 
should  rather  be  called  tenacious  ideas. 

The  association  of  ideas  occurs  by  resemblance,  contrast,  and  con- 
tiguity. In  the  profound  idiots,  with  few  ideas,  there  may  be  an  asso- 
ciation of  them  in  a  very  simple  way — viz.,  the  sight  of  food  is  asso- 
ciated ^vith  the  sensation  of  satisfied  hunger,  and  so  awakens  the  idea 
of  eatino-.  It  is  an  association  of  sensations  rather  than  of  ideas.  The 
association  of  ideas  should  arouse  the  critical  faculty.  The  judgment 
and  reason  in  idiots  are  very  faulty.  They  are  founded  on  an  associa- 
tion of  few  ideas,  lack  precision  and  firmness,  and  find  their  expressions 
in  ambiguous  language.  A  judgment  is  not  ahvays  the  result  of  reason- 
ins:.  For  reasouino',  there  must  be  some  obstacle  to  an  innnediate  con- 
elusion.  Justice,  promptitude,  and  fiimness,  which  are  qualities  of 
judgment  depending  on  the  attention,  are  lacking  in  the  judgments  of 
idiots.  The  idiots  judge  very  falsely  on  account  of  lack  of  attention 
and  of  an  association  of  the  simplest  ideas.  All  their  sense  illusions 
give  rise  to  false  judgments.  Firmness  is  lacking  in  their  judgments, 
as  they  have  so  httle  interest  in  what  they  decide  upon. 

Many  imbeciles  and  feeble-minded,  however,  maintain  their  judg- 
ments with  tenacity.  They  often  have  a  very  high  opinion  of  their 
own  intellectual  faculties.  This  presumption  leads  them  often  to  ex- 
treme blunders.  If  one  of  their  judgments  is  admitted  to  be  just,  they 
become  very  proud  of  it,  and  immediately  set  to  work  to  form  others, 
which  are  generally  absurd.  Doubt  which  suspends  action  is  rarely 
seen  in  any  form  of  idiocy.  The  first  impression  capable  of  forming 
for  them  a  judgment  is  followed  immediately  by  the  act,  like  a  true 
reflex.  Syllogistic  reasoning  does  not  occur  either  in  idiots  or  imbe- 
ciles. Errors  of  the  senses  proceed  from  the  perceptive  apparatus 
rather  than  from  the  sensory  apparatus.  Since  in  idiots  and  imbeciles 
sense  perceptions  are  retained  in  brain  centers  either  undeveloped  or 
diseased,  and  the  memory  pictures  are  consecjuently  either  confused  or 
false,  the  association  of  these  pictures  is  consequently  faults'.  In 
idiots,  as  the  images  are  weak,  the  perceptive  reasoning  is  also  weak  or 
wanting.  In  the^imbecile,  where  the  images  are  more  numerous,  the 
association  may  be  falsified  by  a  badly  acting  perceptive  center.  In 
him  the  association  occurs  so  often  by  contiguity,  and  consequently  the 
deduction  is  very  liable  to  be  erroneous,  as  contiguous  ideas  are  not 
necessarily  related  ;  hence,  incongruous  observations  and  unexpected 
actions. 

SoUier  emphasizes  the  difference  between  idiots  and  imbeciles,  which 
mav    be   seen    in    the  delirium    sometimes    occurring    in    these    cases. 


870  3IENTAL  DISEASES. 

Exceptional  in  the  idiot,  when  it  occurs  it  is  always  in  the  impulsive 
form,  unprovoked  and  without  motive.  It  is  a  delirium  of  acts.  In 
imbeciles  there  are  attacks  of  maniacal  excitement,  with  impulsion  to 
kill,  to  set  on  tire,  or  to  break. 

With  respect  to  the  production  of  ideas,  there  is  little  or  none  in  the 
inferior  types  of  idiocy,  and  in  the  higher  grades  the  imagination  is 
inchoate,  of  no  utility,  and  often  directed  to  things  that  are  evil. 

Will,  Personality,  and  Responsibility. — The  elder  Seguin  looked 
upon  defect  of  will  as  the  basis  of  idiocy,  but  the  will  is  rather  a  diiFuse 
than  a  local  function  of  the  brain.  It  has  no  definite  seat  in  the 
encephalon,  lesion  of  which  would  impair  or  destroy  it.  As  Sollier 
says,  will  in  its  simplest  form  is  manifested  by  actions  accomplished  for 
the  satisfaction  of  natural  needs,  appetites,  and  desires.  Accordingly, 
the  individual  must  have  a  consciousness  of  those  needs.  Such  a  con- 
sciousness may  be  very  much  blunted  in  profound  idiots,  and  conse- 
quently the  will  will  be  almost  entirely  lacking.  Such  an  idiot  is  a 
spinal  being,  and  his  movements  may  be  compared  to  the  reflex  phe- 
nomena seen  in  decapitated  frogs.  In  higher  idiots,  the  will  is  mani- 
fested by  more  complex  movements,  which  are,  however,  capable  of 
becoming  secondarily  automatic.  Voluntary  control  of  the  sphincters 
occurs  only  in  idiots  who  learn  to  walk,  and  not  until  they  have  learned. 
Volitions  do  not  exist  in  the  lowest  order  of  idiots.  The  most  natural 
desires  and  the  most  primitive  instincts  are  absent.  The  first  to  appear 
is  desire  for  food,  but  it  may  manifest  itself  simply  by  a  stretching 
out  of  the  hand  or  a  cry.  In  idiots  in  whom  the  will  is  more  developed, 
and  also  in  imbeciles,  it  finds  its  expression  moi-e  easily  in  actions  than 
in  inhibitions. 

Self-respect,  very  little  developed  in  the  idiot,  plays  a  very  important 
role  in  the  psychology  of  the  imbecile,  and  by  catering  to  it  he  can 
often  be  made  to  do  things  which  would  otherwise  be  impossible  to 
obtain. 

Intellectual  movements,  or  acts  accomplished  under  the  influence  of 
judgment  or  reason,  are  infrequent  in  the  idiot,  and  not  common  in  the 
higher  grades.  Many  idiots  are  incapable  of  choice.  When  the  power 
of  choice  is  present,  it  is  often  exercised  with  difficulty.  He  does  not 
quickly  understand  that  of  two  things  he  must  take  one  and  leave 
the  other — he  wants  to  take  them  both.  It  is  the  same  with  ideas. 
Between  two  desirable  objects,  the  superior  type  does  not  hesitate,  but 
takes  without  reflection  the  one  he  sees  first,  which  he  may  wish  to 
exchange  when  he  sees  the  second. 

In  idiots,  whose  will  and  motor  volitions  are  so  feeble,  suggestion 
produces  little  or  no  results.  It  is  the  contrary  in  many  imbeciles, 
except  in  those  whose  voluntary  impulsiveness  is  too  great.  Ordinarily 
the  higher  grades  are  very  susceptible  to  suggestion,  as  is  seen  by  the 
facility  with  which  mischief  is  done  by  a  band  of  imbeciles  which  has 
been  led  on  by  one  of  their  number.  If  suggestion  is  possible  in 
imbeciles,  it  shows  that  the  ideas  which  they  already  possess  are  very 
unstable,  and  are  easily  replaced  by  new  ones.  It  has  a  great  analogy 
with  the  suggestibility  of  the  hysterical. 


IDIOCY.  871 

Consciousness  and  Personality. — As  consciousness  is  but  a  phe- 
nomenon added  to  psychic  processes,  and  not  producing  them,  and  as 
the  personality  is  the  coordination  of  psychic  acts,  it  is  necessary  to 
form  by  deduction  our  conclusions  as  to  these  two  attributes  in  the 
class  of  people  we  are  studyiug.  In  absolute  idiots  it  is  not  probable 
that  any  act  is  accompanied  by  consciousness.  In  higher  idiots,  in 
whom  life  is  but  little  more  than  a  succession  of  disconnected  moments, 
it  is  not  possible  to  say  whether  they  have  consciousness  or  not ;  but  the 
personality,  if  present,  must  be  very  rudimentary,  since  an  essential 
of  its  existence  is  a  proper  appreciation  of  the  continuity  of  events. 

For  an  individual  to  have  consciousness  of  a  psychic  act,  it  is 
necessary  that  the  exciting  stimulus  have  a  certain  duration  and  inten- 
sity. Such  factors  in  the  stimuli  are  generally  wanting  in  idiots  ;  and 
so  it  is  probable  that  most  of  their  psychic  phenomena  occur  without 
consciousness  ;  and  if  there  is  consciousness,  it  must  be  very  feeble. 
The  distinction  between  the  ego  and  the  non-ego  is  not  made  by  abso- 
lute idiots,  and  is  but  feebly  present  in  the  higher  idiots. 

In  many  imbeciles  consciousness  may  be  wanting  or  feeble,  but  in 
some  it  is  clearly  present,  together  with  a  perfect  idea  of  their  per- 
sonality. Further,  sometimes  in  delirium  they  have  ideas  of  grandeur, 
showing  an  exaggerated  conception  of  personality. 

Responsibility. — All  lower  types  of  idiots  are  unable  to  manage 
their  own  aifairs  or  to  enjoy  their  civil  or  political  rights,  but  those  of  a 
higher  degree,  who  are  at  liberty,  may  have  these  rights. 

Psychological  Evolution. — In  every  degree  of  idiocy  there  comes 
a  time,  as  Soliier  well  says,  when  the  education  stops  and  further  mental 
progress  ceases,  and  when  the  only  hope  is  to  retain  the  results  which 
have  been  gained.  This  acme  of  development  varies  for  the  different 
psychic  functions,  so  that  one  faculty  may  still  improve,  while  another 
has  already  reached  its  cessation  point.  The  senses  continue  to  develop 
for  the  longest  time,  then  the  sentiments,  and  the  intelligence  the 
shortest.  This  is  true  of  all  classes,  though  the  periods  are  longer  in 
the  higher  grades,  where  all  of  the  faculties  are  more  equally  and  pro- 
portionally developed.  Thus,  in  inferior  types  intellectual  progress 
may  cease  at  the  age  of  six  or  seven,  and  the  sentiments  and  senses  con- 
tinue their  development  to  eighteen  or  twenty,  while  in  superior  grades 
the  improvement  of  senses,  sentiments,  and  intellect  may  cease  about 
the  same  time — viz.,  at  puberty. 

Sometimes  the  faculties  remain  stationary,  at  others  they  retrograde 
when  the  limit  of  development  is  reached.  Retrogression  follows  the 
same  law  as  dementia — namely,  progressive  enfeeblement  of  will,  intel- 
ligence, sentiments,  and  sensations,  in  the  order  named.  When  retro- 
gression begins  in  the  simpler  forms  it  is  very  rapid,  but  in  the  higher 
types  goes  more  slowly  and  more  irregularly.  Purely  intellectual  gifts 
which  they  have  acquired  (reading  and  writing)  disappear  very  rapidly. 
In  the  intellectual  downfall  of  the  superior  types  one  sees  from  time  to 
time  flashes  of  intelligence,  like  reflections  from  their  weakening  minds, 
but  such  are  not  observed  in  the  lower  forms. 

General  Pathological  Anatomy. — There  has  been  accumulated  in 


872  3IEXTAL   DISEASES. 

literature  of  late  years  a  great  deal  of  valuable  matter   relating  to  the 
pathology  and   morbid  anatomy  of  idiocy,  so   that  much  new  light  has 
been  shed  upon  a  somewhat  obscure  subject.     The  investigations  of 
Sachs  and  myself  ^  into  the  causation  of  the  cerebral  paralyses  of  chil- 
dren, which  are  so  frequently  associated  with  the  various  degrees   of 
mental  impairment,  from  feeble-mindedness  to  profound  idiocy,  and  in 
which  we  found  meningeal  hemorrhage  to  be  so  commonly  the  primary 
lesion,  might  well  give  rise  to  the  belief  that  in  a  majority  of  cases  of 
idiocy  without  paralysis  and   in   idiocy  associated  with  epilepsy  we   are 
confronted  with  the  same   initial    lesion.      The   site   of  the   meningeal 
hemorrhage  is  the  determining  factor  in  the  establishment  of  the  symp- 
toms.     If  the  Rolandic  area  be  mainly  implicated,  either  on  one  or  on 
both  sides,  we  have  a  hemiplegia  or  diplegia  as  the  result,  and  these 
paralyses  may  be  severe  or  light  according  to  extent  of  the  hemorrhage, 
and  may  be  associated  with  idiocy  or  epilepsy,   depending  also  upon  the 
extent  of  the  lesion  and  upon  the  amotmt  of  irritation.     Again,  I  have 
seen  a  case  in  which  there  was  left  hemianopia,  epilepsy,  and  very  slight 
mental  impairment,  pointing  to  a  meningeal  hemorrhage  over  the  right 
occipital  lobe.      Probably,   too,   some  of    the   cases   of   arrested  devel- 
opment   of  the   sjjeech,    with   or  without    enfeebled  mind,  are    due  to 
the  same  cause.     It  may  be  assumed  also  that  meningeal  hemorrhage 
often  occurs  as  the  initial  lesion  in  what   appears  to  be  idiopathic  epi- 
lepsy.     The  symptom  or  syndrome   produced  then  will  depend  upon 
the  location  and  extent  of  the  initial    lesion.     Asphyxia  at  birth  and 
convulsions  shortly  after  birth  are  in  themselves  significant  of  menin- 
geal hemorrhage,  and   in  our  study   of  etiology  we  observe  the   great 
frequency  of  these  symptoms  in  the  history  of  idiocy.     At  our  autop- 
sies,  which  are  nearly  always   made  years    after  the  initial  lesion,  we 
find  only  terminal  pathological  states,  such  as  atrophy,  general  sclerosis, 
and  cysts,  and,  unfortunately,  these  conditions  are  not  pathognomonic  of 
antecedent  hemorrhage,   for  they  also  are  the  terminal  states  for  em- 
bolism,  thrombosis,    cerebral    hemorrhage,    meningitis,    and    meningo- 
encephalitis.     What  other  evidence  have  we  tliat  proves  the  enormous 
preponderance  of  meningeal  hemorrhage  in  the  etiology  of  the  terminal 
pathological  conditions  ?     It  is  in  the  testimony  of  the  investigators  of 
the  causes  of  still-birth.      For  instance,  Litzmann-  examined  161  still- 
born children,  finding  in  them  35  cases  of  meningeal  hemorrhage.      Par- 
rot,^ in  34  autopsies  on  the  new-born,  found  5  with  blood  in  the  arach- 
noid cavity  and  26  with  hemorrhage  into  the  subarachnoid  space. 

The  study  of  Sarah  J.  McXtitt,^  of  Xew  York,  in  1885,  of  10 
similar  cases  added  valuable  testimony  to  that  already  given,  and 
showed  the  relation  between  meningeal  hemorrhage  and  asphyxia  and 
convulsions  in  the  new-born  in  a  manner  not  to  be  gainsaid. 

^"The  Cerebral  Palsies  of  Early  Life,  Based  on  a  Study  of  One  Hundred  and 
Forty  Cases,"  "Jour.  Nerv.  and  Ment.  Dis.,"  ^lay,  1890.  See  also  paper  on  same 
subject  by  author,  Louis  Starr's  ' '  Text-book  of  Diseases  of  Children, "  Phila.,  1894,  and 
Sachs'  "Nervous  Diseases  of  Children,"  New  York,  1895. 

2  "  Arclnv  fur  Gyn.,"  Bd.  xvi,  1880. 

*  "  Clinique  des  Nouveau-nes, "  Paris.  1877.  *  "  A«ier.  Jour,  of  Obstetrics."" 


IDIOCY. 


873 


Allusion  is  elsewhere  made  to  Herbert  R.  Spencer's  130  autopsies 
in  still-born  children,  in  which  there  were  53  instances  of  hemorrhage 
from  the  pia  and  arachnoid. 

Thus,  the  evidence  before  us  in  favor  of  meningeal  hemorrhage  as 
the  initial  lesion  in  a  large  proportion  of  cases  of  idiocy  is  most  con- 
vincing. Some  idea  of  the  character  of  the  terminal  states  found  in 
idiocy  may  be  derived  from  the  studies  of  Wilmarthi  and  Bourneville.^ 
The  former  communicates  the  results  of  100  autopsies,  which  he  sum- 
marizes as  follows  : 

Sclerosis  with  atrophy,  12  ;  sclerose  tubereuse,  6  ;  diffuse  sclerotic 
change,  7  ;  degenerative  changes  in  vessels,  ganglionic  cells,  or  medul- 
lary substance,  not  constituting  true  sclerosis,  15  ;  hydrocephalic,  5  ; 
general  cerebral  atrophy,  2;  non-development  in  various  forms,  16; 
infantile   hemorrhage,  1  ;    extensive  adhesion  of  membranes   from  old 


Fig.  336. — Brain  of  a  diplegic  idiot,  showing  atrophy  of  the  convolutions  over  large  symmetrical  areas 
—not  a  true  parencephalia.     (See  history  of  case,  "  Proc.  N.  Y.  Path.  Soc,"  1894,  p.  94.) 

meningitis,  3  ;  angiomatous  condition  of  cerebral  vessels  (with  degener- 
ative changes),  1  ;  glioma  (with  sclerosis),  1  ;  porencephalia  (with 
non-development),  1  ;  of  31  cases  where  actual  disease  or  imperfect 
development  of  the  brain  proper  was  not  demonstrated,  there  was 
hypertrophy  of  the  skull,  6  ;  acute  softening  (recent),  2  ;  demimicro- 
cephalic,  2  ;  when  the  brain  was  above  usual  weight,  but  the  convolu- 
tions large  and  very  simple  in  their  arrangement,  2. 

Our  examination  of  this  summary  discloses  the  fact  that  atrophies 
and  diffuse  sclerosis  were  demonstrated  in  21  of  the  cases  and  tuberous 
sclerosis  in  6.  It  is  probable  that  the  tuberous  form  of  sclerosis  has  a 
pathology  different  from  that  of  the  diffuse  form  and  more  resembling 
the  disseminated  sclerosis  of  neuropathologists.  Fifteen  of  Wilmarth's 
cases  are  recorded  as  presenting  degenerative  changes  in  ves.sels,  gan- 

1  "Proceedings  A.ss'ii  Amer.  Inst.  Idiots  and  Feeble-minded,"  1891. 

2  "Recherches  sur  I'epilepsie,  I'idiotie,"  etc.,  Paris,  1880-1897. 


874  MENTAL   DISEASES. 

glionic  cells,  or  medullary  substance,  "  not  constituting  true  sclerosis." 
There  was  evidently  some  resemblance  to  sclerosis,  or  this  author  would 
not  have  qualified  his  description  thus ;  and  it  is  more  than  probable 
that  the  condition  would  have  been  pronounced  one  of  genuine  diflFuse 
sclerosis  by  experts  at  the  present  day.  Wilmarth  notes  16  cases  of 
non-development  in  various  forms.      He  writes,  in  this  connection  : 

"  Non-development  is  found  in  several  forms.  A  portion  of  the 
cortical  substance  may  be  thin,  and,  instead  of  following  the  typical 
arrangement  of  the  fully  developed  brain,  form  a  number  of  irregular 
folds,  which  may  be  so  small  and  numerous  as  to  resemble  a  mass  of 
angle-worms." 

This  is  evidently  the  condition  which  we  know  as  microgyria,  a  true 
pathological  process  probably  due  to  a  vascular  lesion  (thrombosis  or 
embolism),  and  not,  therefore,  a  fault  of  development.  Wilmarth's  ob- 
servations were  made,  many  of  them,  years  ago,  before  neuropathology 
had  attained  its  present  precision,  and  hence  have  not  the  value  of  later 
researches,  such  as  those  undertaken  at  Bicetre  and  Upsala. 

Hammarbersr  ^  has  made  one  of  the  most  valuable  contributions  to 
the  study  of  the  pathology  of  idiocy  in  literature.  His  study  enters 
into  the  details  of  the  examination  of  the  brains  of  nine  cases  of  idiocy, 
imbecility,  and  feeble-mindedness.  Several  of  these  were  epileptic  and 
paralytic  idiots.  His  pathological  investigations  were  controlled  by  the 
microscopic  examination  of  twelve  normal  brains.  The  results  were 
briefly  as  follows  :  In  all  of  the  cases  of  idiocy  a  more  or  less  large 
part  of  the  cortex  showed  arrest  of  development  at  a  stage  correspond- 
ing to  either  an  embryonal  period  or  the  period  of  early  infancy.  Only 
a  small  number  of  cells  reached  their  higher  development  or  were  de- 
stroyed during  the  growth  of  the  cortex.  The  mental  defects  were  in 
direct  proportion  to  the  defects  of  the  development  of  the  cells,  and 
were  greater  the  earlier  the  period  of  arrest  of  development. 

As  regards  hydrocephalic  idiocy,  the  true  pathogeny  of  hydroceph- 
alus is  unknown.  It  is  generally  explained  as  being  due  to  a  chronic 
intraventricular  meningitis,  a  congestion  of  the  ependyma.  But  in 
many  of  these  cases  nothing  abnormal  is  observed  about  the  ependyma 
save  thickening.  It  is  possible  that  a  careful  study  of  the  manner  of 
secretion  of  the  cerebrospinal  fluid  and  of  the  relations  existing  between 
the  ependyma  and  the  external  serous  membrane  of  the  brain  may 
help  to  elucidate  the  origin  of  the  disorder ;  for  there  is  some  reason  for 
believing  that  a  sort  of  current  of  fluid  flows  from  the  ventricles  into 
the  exterior  serous  cavity  through  the  foramen  of  Magendie,  the 
foramina  of  Mierzejewsky,  and  two  other  foramina  which  have  been 
described,  but  are  of  uncertain  existence.  The  ventricular  walls  secrete 
the  cerebrospinal  fluid  and  the  exterior  serous  cavity  absorbs  it,  accord- 
ing to  this  theory.  Thus,  then,  there  may  be  three  processes  by  which 
primary  hydrocephalus  may  be  induced  :  hypersecretion  in  the  ventric- 
ular spaces,  occlusion  of  the  foramina  mentioned,  and  disorder  of  the 
absorbent  apparatus.  An  interesting  study  of  the  subject  along  this 
line  might  be  made. 

^  "  StudieQ  liber  Kliuik  und  Pathologic  derldiotie,"  by  C,  Hammarberg,  Upsala, 
1895. 


IDIOCY. 


875 


When  the  fin  id  begins  to  increase  in  the  ventricles,  these  become 
dihited,  as  a  rule  equally,  oeeasionally  unequally,  from  obliteration  of  the 
foramen  of  Monro.  The  dilatation  may  be  restricted  tt>  the  lateral  ven- 
tricles, or  may  include  the  third  and  fourth  also.  With  the  distention 
of  the  ventricles  compression  of  the  brain-substance  takes  place,  giving 
rise  to  functional  impairment  of  various  kinds  and  degrees.  With 
increase  of  pressure,  atrophy  of  the  compressed  parts  occurs.  The 
septum  between  the  ventricles  may  disappear  and  the  brain-envelope 
become  thin   as  paper,  so  that  the  hydrocephalus  is  like  one  enormous 


Fig.  337. — Brain  of  a  blind  heraiplegie  idiot.    Atrophy  and  microgyria  in  both  occipital  lobes.     (See 
history  of  case,  "  Proc.  N.  Y.  Path.  Soc,"  1894,  p.  98.) 


cyst  filling  the  cranial  cavity.  The  basal  ganglia  and  brain-stem 
become  flattened.  Examination  of  the  cerebral  envelope  shows  atrophy 
and  degeneration  of  cells  and  fibers.  The  distention  may  go  on  until 
the  cerebral  tissues  and  the  membranes  vanish  almost  entirely.  The 
amount  of  fluid  has  been  known  to  reach  six,  eight,  ten,  twenty,  and 
even  twenty-seven  pints.  The  following  is  an  instance  in  point  (a  case 
from  the  Randall's  Island  Hospital  for  Idiots,  the  autopsy  of  wdiich  I 
reported  at  the  New  York  Pathological  Society.  See  "  Proceedings," 
1894,  p.  94)  : 

A  female    child,    aged    eighteen    months ;    hydrocephalus,   whether 


876 


3IENTAL  DISEASES. 


congenital  or  acquired  unascertained.  Circumference  of  head,  51.5  cm. ; 
anteroposterior  diameter,  18  cm. ;  greatest  ti'ansverse  diameter,  15  cm. ; 
naso-occipital  arc,  32  cm. ;  binauricular  arc,  34  cm. 

Blindness  and  nystagmus ;  widely  gaping  fontanels ;  spastic  di- 
plegia ;  occasional  conyulsions,  and  just  before  death  opisthotonos. 
At  the  autopsy  sixty-four  ounces  of  reddish  serum  were  first  removed 
by  tapping  the  anterior  fontanel.  The  skull  and  dura  were  exceed- 
ingly thin.  The  falx  cerebri  had  disappeared.  Cutting  through  the 
thin  dura,  nothing  was  to  be  seen  of  any  brain  proper  in  the  great  cavity 
of  the  head.  The  membranes  usually  covering  the  cerebrum  had  dis- 
appeared with  that  organ.  At  the  base  of  the  skull  the  floors  of  the 
ventricles  and  basal  ganglia  stood  out  prominently,  and  back  of  these 
parts,  lying  on  the  tentorium,  were  the  only  vestiges  of  a  cerebrum — 


-Brain  aijJ  -kul 


cephalas. 


parts  of  the  two  occipital  lobes.  On  removing  the  tentorium,  the  cere- 
bellum was  found  to  be  of  about  normal  size.  Microscopical  exami- 
nation showed  degeneration  and  atrophy  of  the  lateral  columns  of  the 
cord  (Fig.  338). 

In  this  case,  then,  we  have  to  do  with  distention  and  atrophy  of  the 
encephalon  pushed  to  its  greatest  extreme. 

Case  IV,  in  a  series  of  auto23sies  by  Bourneville,  is  a  good  illustra- 
tion of  the  nature  of  the  process  of  compression  and  atrophv.  A  girl, 
a  comj^lete  idiot,  died  at  the  age  of  about  two  years.  Five  hundred 
grams  of  fluid  were  found  in  the  brain-cavity,  the  brain-envelope 
having  become  merely  a  sac  of  varying  thickness.  For  instance,  in 
the  right  hemisphere,  over  the  whole  of  the  temporo-occipital  region, 
the  wall  of  cerebral  substance  was  but  a  millimeter  in  thickness,  and 
at  one  place  here,  near  the  fissure  of  Sylvius,  the  brain-substance  was 


IDIOCY.  877 

absent  altogether  at  a  space  of  four  centimeters  in  diameter,  closed 
merely  by  a  fine  meningeal  veil.  In  this  case,  then,  the  process  of 
complete   atrophy  of  the  brain  was  arrested  by  death. 

As  the  ventricidar  cavities  dilate,  pushing  the  brain-envelope  with 
them,  the  skull-cavity  is  distended  and  the  cranial  bones  are  separated, 
made  thinner,  and  expanded  in  area.  The  enlargement  of  the  head  is 
directly  proportional  to  the  youth  of  the  patient.  Cases  beginning  be- 
fore or  shortly  after  birth  will  present  greater  expansion  of  the 
cranial  cavity  than  such  as  have  a  later  origin.  Sometimes  some 
sutures  give  way  and  others  become  synostosed.  Where  sutures  are 
separated  Wormian  bones  often  form,  or  a  membranous  connection  is 
established  between  the  cranial  bones. 

Occasionally,  in  these  cases  of  primary  hydrocephalus,  the  defects  of 
brain-substance  are  not  due  to  pressure-atrophy,  but  there  is  an  associ- 
ated condition  of  malformation  or  defect.  Thus,  in  an  autopsy  of 
Bourneville's,  on  a  girl  about  thirteen  years  of  age,  with  congenital 
hydrocephalus,  idiocy,  and  epilepsy,  the  hemispheres  of  the  cerebellum 
were  totally  absent,  the  cerebellum  being  represented  by  the  vermis, 
which  was  the  size  of  a  pigeon's  egg.  Perhaps  such  a  defect  is  due  to 
a  pressure-atrophy  beginning  very  early  in  fetal  life. 

As  regards  the  pathology  of  secondary  hydrocephalus,  we  possess  more 
definite  knowledge.  In  this  the  internal  hydrocephalus  is  caused  by  ob- 
struction of  the  veins  of  Galen,  or  by  obliteration  of  the  foramina  of 
Monro,  Magendie,  or  Mierzejewski.  Common  causes  are  tumors  of 
the  cerebellum,  such  as  sarcomata  and  tubercles.  Meningitis  may  act 
in  the  same  way.  The  amount  of  hydrocephalus,  ventricular  dilatation, 
and  expansion  of  the  skull  thus  induced  will  depend  directly  upon  the 
youth  of  the  infant  or  child.  As  a  rule,  secondary  hydrocephalus  never 
reaches  the  extent  of  the  primary  form,  owing  to  the  rapidly  fatal  nature 
of  its  cause.  In  these  cases  we  seldom  see  pressure  eifects  beyond  flat- 
tening of  the  convolutions  and  moderate  expansion  of  the  cranial  vault. 

An  exceptional  and  an  extremely  interesting  case  was  one  upon  whom 
I  made  an  autopsy  at  Randall's  Island,  not  long  ago.  It  was  a  case  of 
very  marked  hydrocephalus  in  a  child  of  four  years,  in  which  a  small 
tumor  of  the  pineal  gland,  the  size  of  a  small  hazel-nut,  compressed 
and  obliterated  the  aqueduct  of  Sylvius.  Both  of  the  lateral  ventricles 
were  enormously  distended,  the  left  more  than  the  right,  and  contained 
twenty-four  ounces  of  clear  fluid.  The  third  ventricle  was  also  widely 
dilated.  The  fourth  ventricle  was  of  normal  size.  Microscopical  sec- 
tions of  the  quadrigcminal  region  revealed  the  obliteration  of  the  aque- 
duct. The  tumor^was  apparently  tubercular,  but  was  not  examined,  it 
having  been  mislaid  and  lost. 

The  cases  of  acute  hydrocephalus  due  to  meningitis  serosa,  and  the 
cases  in  which  a  defect  of  brain-substance  is  counterbalanced  by  an  equal 
bulk  of  cerebrospinal  fluid,  do  not  commonly  fall  under  this  heading. 

In  chronic  hydrocephalus  internus  there  seems  to  be  a  special  sus- 
ceptibility of  the  membranes  to  acute  disease,  so  that  at  autopsy  it  is 
not  uncommon  to  find  evidence  of  an  acute  meningitis,  simple,  hemor- 
rhagic, suppurative,  or  tubercular. 


MENTAL  DISEASES. 


The  fluid  found  in  hydrocephalic  idiots  has  been  frequently  analyzed. 
In  a  case  of  Bourneville's  the  analysis  of  the  hydrocephalic  fluid,  with- 
drawn nine  hours  after  death,  resulted  as  follows  :  Color,  pale  yellow  ; 
aspect,  clear  after  standing  ;  reaction,  neutral ;  odor,  like  that  of  blood  ; 
consistence,  slightly  viscous;  density,  1.006;  organic  matter,  1.65; 
salts,  10;  total  fixed  solids,  11.65;  phosphoric  acid,  0.22;  sodium 
chlorid,  0.80 ;  albumin,  0.26  ;  leukocytes,  very  few ;  red  blood-cor- 
puscles, considerable. 

In  microcephalic  idiocy  we  recognize  three  distinct  classes  : 

1.  Morphological  microcephaly,  in  which  there  are  no  pathological 
changes  in  the  brain,  but  simply  a  brain  arrested  in  its  development 
with  persistent  fetal  morphology. 

2.  Pathological  microcephaly,  in  which  the  small  size  of  the  head 
is  determined  by  morbid  processes  in  the  brain  (such  as  meningeal  hem- 
orrhage, thrombosis,  porencephalic  defects,  etc.). 

3.  Mixed  cases  of  microcephaly,  in  which  pathological  processes  are 
superadded  to  or  associated  with  true  morphological  microcephaly. 

The  following  table  gives  a  summary  of  the  pathological  conditions 
responsible  for  most  cases  of  idiocy  : 


Etiological  Factors. 

Primary  Lesions. 

Terminal  Conditions  Found 
AT  Autopsy. 

Hereditary  degeneracy. 

Developmental    defects    of 
portions    of   the    brain, 
such  as  corpus  callosum, 
one  hemisphere  or  part 
of  a  hemisphere. 

Same,  with  compensatory 
hydrocephalus  internus, 
externus,  or  both  ;  com- 
pensatory thickening  of 
skull. 

Hereditary  degeneracy. 

Micrencephalus,    with     or 
without  defects. 

Same.  Brain-substance 
often  sclerotic  ;  deficient 
in  microscopical  ele- 
ments. Sometimes  com- 
pensatory hydrocephalus. 

Hereditary  degeneracy. 

Agenesis  corticalis  ;  slight 
changes  in  gross  appear- 
ance of  brain  ;  maldevel- 
opment  of  microscopical 
elements. 

Same.  Sometimes  hydro- 
cephalus externus. 

Vascular  disorders  of  fetal 
brain. 

Partial  defects  like  poren- 
cephalia, microgyria. 

Same.  Compensatory  hy- 
drocephalus and  thicken- 
ing of  the  skull ;  atrophy 
and  sclerosis  of  affected 
convolutions  or  lobes. 

Diseases  of  mother  or  trau- 
ma to  mother.      •• 

Fetal    disorders,    such     as 
syphilis,      asphyxia      at 
birth,     prolonged     labor, 
infantile  convulsions, 
febrile  diseases  of  child, 
cerebral  diseases  of  child. 

Meningeal       hemorrhage  ; 
thrombosis  ;     embolism  ; 
cerebral        hemorrhage ; 
meningitis ;       meningo- 
encephalitis. 

Atrophy  ;  diffuse  sclerosis  ; 
cysts  ;  meningo-encepha- 
litis. 

Uncertain   fetal    and   post- 
natal causes. 

Tumor  sometimes  ;  oftener 
unknown. 

Hydrocephalus. 

Antecedent   infectious   dis- 
eases of  mother  or  child  (?). 

Tuberous  sclerosis. 

Tuberous  sclerosis. 

IDIOCY.  879 

In  amaurotic  idiocy  but  six  autopsies  have  been  made,  and  thus  far 
the  changes  found  may  be  considered  to  be  simply  degeneration  of  the 
gray  matter  of  the  cortex  and  of  the  anterior  horns  of  the  cord 
(Sachs).  1 

Diagnosis  and  Prognosis  of  Idiocy. — Diagnosis  of  Idiocy  in 
General. — It  is  seklom  difficult  to  make  a  diagnosis  of  idiocy  in  child- 
hood when  the  individual  lias  reached  such  a  stage  of  development 
that  backwardness  and  deficiency  stand  out  in  prominent  contrast  to 
the  normal  average  of  intelligence  in  children  of  the  same  age.  Occa- 
sionally, however,  we  have  to  deal  with  some  species  of  insanity  in 
childhood,  in  which  case  the  matter  of  diagnosis  is  important  because 
of  the  more  favorable  outlook  for  insanity.  There  are  not  a  few  pa- 
tients cared  for  in  institutions  for  the  feeble-minded  and  idiots  in  which 
insanity  has  been  the  original  factor  in  the  mental  impairment,  and 
when  the  histories  of  such  are  obscure,  it  is  almost  impossible  to  dis- 
tinguish between  ordinary  idiocy  and  what  may  be  truly  termed  a  ter- 
minal dementia  following  upon  some  acute  insanity  of  childhood.  In 
these  cases  residual  symptoms  of  a  psychosis  can  be  our  only  guide. 

The  diagnosis  of  some  form  of  idiocy  in  infancy  is  far  from  easy 
unless  one  familiarizes  himself  thoroughly  with  the  manifold  steps  of 
development  for  the  first  few  years  of  existence.  Early  diagnosis  is 
of  the  utmost  importance,  not  only  for  the  benefit  of  the  unfortunate 
child  itself,  but  on  account  of  the  deep  solicitude  of  the  parents  for  its 
future.  One  of  the  chief  aids  in  differentiation  will  be  found  in  a 
study  of  the  physical  condition  of  the  infant.  The  sha23e  and  size  of 
the  head  should  be  carefully  noted  and  compared  with  normal  shapes 
and  statistics.  Unfortunately,  there  are  no  elaborate  tables  of  head 
measurements  in  infants  and  children  as  yet  made  which  can  be  looked 
upon  as  a  final  establishment  of  the  normal  averages,  but  the  following 
figures  are  fairly  representative  of  cranial  measurements  : 

Circumference  at  birth 36  cm.  in  both  sexes. 

Biuauricular  arc 22    "     "     " 

Naso-occipital  arc 22    "'     "     "       " 

At  the  age  of  one  year  these  dimensions  have  increased  to — 

Circumference      44  cm.  in  both  sexes. 

Binauricular  ai'c 27    "     "     "        " 

Naso-occipital  arc 30    "     "     "       " 

Malformation  and  asymmetry  of  the  head  should  be  taken  into  con- 
sideration. The  various  malformations  are  treated  of  in  another  chapter. 
The  presence  of  marked  anatomical  stigmata  of  degeneration  is  of  sig- 
nificance. Paralvsis  of  a  limb  or  limbs,  if  of  cerebral  origin,  is  of  sfreat' 
importance,  indicating,  as  it  does,  some  lesion  of  the  brain,  which  may 
retard  or  restrict  mental  development  and  lead  to  paralytic  or  epileptic 
idiocy,  or  both.      Some  of  the  morbid  movements,  such  as  nvstagmus, 

^  "  A  Case  of  Amaurotic  Family  Idiocy  with  Autopsy,"  by  Frederick  Peterson, 
M.  D.,  "Jour.  Nery.  and  Meut.  Dis.',"  July,  1898. 


880  MENTAL   DISEASES. 

ataxia,  chorea,  or  athetosis,  may  be  present,  and,  as  symptoms  of  dis- 
order of  the  central  nervous  system,  should  lead  to  a  careful  investi- 
gation of  the  whole  mental  and  physical  organization. 

While  it  is  frequent  to  find  evidence  of  idiocy  immediately  after 
birth  in  bodily  and  especially  in  cranial  and  facial  characteristics,  yet 
after  careful  examination  as  to  imperfect  action  of  the  sensations  and 
perceptions,  we  may  sometimes  recognize  idiocy  in  cases  where  physical 
evidence  is  wanting.  The  child  may  not  learn  easily  to  take  the  breast. 
Its  cry  is  diiferent  from  that  of  other  children.  It  cries  without 
motive.  Sometimes  there  is  congenital  blindness  or  congenital  deaf- 
ness (there  is  always  deafness  in  every  child  for  several  days  after 
birth).  In  the  normal  child  the  sense  of  smell  may  be  stimulated  im- 
mediately after  birth,  and  taste  is  evident  in  a  few  days.  In  the  idiot 
these  special  senses  may  be  retarded  in  their  development,  or  absent. 
The  movements  of  the  eyes  are  generally  irregular,  and  strabismus  is 
frequent  until  the  end  of  the  second  month  in  normal  children,  so  that 
in  the  diagnosis  of  idiocy  this  can  not  be  relied  upon  as  significant  unless 
the  eye-movements  are  imperfect  after  the  third  month.  In  the  normal 
child  the  eyes  follow  a  light  between  the  third  and  fourth  weeks  ;  in  idiots 
this  ability  may  be  retarded  indefinitely.  The  normal  child  starts  at 
gentle  touches  on  the  third  day  after  birth.  The  new-born  idiot  maybe 
immobile  or  feeble  in  its  reactions  to  cutaneous  stimuli.  The  normal 
child  laughs  at  tickling  in  the  eighth  week,  while  the  idiot  or  imbecile 
is  not  incited  to  laughter  ordinarily  at  all  in  the  earliest  years  of  life. 
From  these  facts  it  follows  that  in  defectives  we  must  examine  the  sen- 
sory organs  themselves,  so  far  as  possible,  for  defects,  as  well  as  study 
their  reactions  and  impaired  perceptions  of  sensations. 

Preyer,  in  his  work  on  '•  The  Mind  of  the  Child,"  gives  a  conspectus 
of  the  development  of  the  normal  faculties  during  the  first  forty  months 
of  the  child's  life,  and  the  following  brief  abstract  is  made  therefrom  for 
purposes  of  comparison  with  the  mental  development  of  the  idiot : 


NORMAL  CHILD. 

First  Month. — Sensitive  to  light  as  early  as  first  and  second  days. 
Pleasure  in  light  of  candle  and  in  bright  objects  on  eleventh  day. 
Hears  on  fourth  day.  Discriminates  sounds  last  two  weeks  of  month. 
Starts  at  gentle  touches  second  and  third  days.  Sensibility  to  taste  about 
end  of  first  week.  Strong-smelling  substances  produce  mimetic  move- 
ments at  birth. 

Pleasure  first  days  in  nursing,  in  bath,  in  sight  of  objects. 

Discomfort  first  clays  from  cold,  wet,  hunger,  tight  clothing. 

Smiles  on  twenty-sixth  day. 

Tears  on  twenty-third  day. 

Vowel-sounds  in  first  inonth. 

Memory  first  active  as  to  taste  and  smell ;  then  as  to  touch,  sight, 
hearing. 

Incoordinate  movements  of  the  eyes. 


IDIOCY.  881 

Sleeps  two  hours  at  a  time,  and  sixteen  hours  in  twenty-four. 

Reflexes  active. 

Second  Month. — Strabismus  occasional  until  end  of  month.  Recog- 
nizes human  voices  ;  turns  head  toward  sounds.  Pleased  with  music 
and  with  human  face.  Sleeps  three,  sometimes  five  or  six,  hours. 
Laughs  from  tickling  at  eighth  week.  Clasps  with  its  four  fingers  at 
eighth  week.  First  consonants  from  fort}'-third  to  fifty-first  days 
{am-ma,  ta-hu,  go,  ara). 

Third  Month. — Sixty-first  day,  cry  of  joy  at  sight  of  mother  and 
father ;  eyelids  not  completely  raised  when  child  looks  up.  Accommo- 
dates at  ninth  week.  Notes  sound  of  watch  at  ninth  week ;  listens 
with  attention. 

Fourth  Month. — Eye-movements  perfect.  Objects  seized  are  moved 
toward  the  eyes.  Grasps  at  objects  too  distant.  Joy  at  seeing  self  in 
mirror.  Contraposition  of  thumb  in  grasping  at  fourteenth  week. 
Head  held  up  permanently.  Sits  up  with  back  supported  at  fourteenth 
week.     Besfinnino-  to  imitate. 

Fifth  Month. — Discriminates  strangers.  Looks  inquiringly.  Pleas- 
ure in  crumpling  and  tearing  newspapers,  pulling  hair,  ringing  a  bell. 
Sleeps  ten  to  eleven  hours  without  food.  Desire  shown  by  stretching 
out  arms.     Seizes  and  carries  objects  to  mouth.      Consonants  /  and  I: 

Sixth  Month. — Raises  self  to  sitting  posture.  Laughs,  and  raises 
and  drops  arms  when  pleasure  is  great.  "  Crows  "  with  pleasure.  Com- 
pares image  of  father  in  mirror  with  original. 

Seventh  Month. — Astonishment  shown  by  open  mouth  and  eyes. 
Recognizes  nurse  after  four  weeks'  absence.  Sighs.  Imitates  move- 
ments of  head,  of  pursing  lips.  Averts  head  as  sign  of  refusal. 
Places  himself  upright  on  lap. 

Eighth  Month. — Astonishment  at  new  sounds  and  sights  ;  at  imita- 
tions of  cries  of  animals. 

Ninth  Month. — Stands  on  feet  without  support.  More  interest 
shown  in  things  in  general.  Strikes  hands  together  with  joy.  Shuts 
eyes  and  turns  head  away  when  something  disagreeable  is  to  be  en- 
dured. Fear  of  dog.  Turns  over  when  laid  face  downward.  Turns 
head  to  light  when  asked  where  it  is.  Questions  understood  before 
child  can  speak.     Voice  more  modulated. 

Tenth  Month. — Sits  up  without  support  in  bath  and  carriage.  First 
attempts  at  walking  at  forty-first  week.  Beckoning  imitated.  Missed 
parents  in  absence,  also  a  single  ninepin  of  a  set.  Can  not  repeat  a 
syllable  heard.  Monologue  and  hints  at  imitation  (»ia,  pappa,  tatta, 
appapa,  baba,  tdtd^  pa,  rrrr  rrra). 

Eleventh  Month. — Screaming  quieted  by  "  sh."  Sitting  becomes 
habit  for  life.  Stands  without  support.  Stamps.  Syllable  correctly 
repeated.  AYhispering  begins.  Consonants  b,  p,  t,  d,  m,  n,  r,  I,  g,  Jc, 
vowel  a  most  used,  u  and  o  rare,  i  very  rare. 

Twelfth  Month. — Pushes  chair.  Can  not  raise  self  or  walk  Avithout 
help.     Obeys  command,"  Give  the  hand." 

Thirteenth  Month. — Creeps.      Shakes  head  in   denial.     Says  p«j9a 
and  mamma.     Understands  some  words  spoken. 
56 


882  3IENTAL   DISEASES. 

Fourteenth  Month. — Can  not  walk  without  suj^port.  Raises  himself 
by  chair.     Imitates  coughing  and  swinging  of  arms. 

Fifteenth  Month. — Walks  without  support.  Laughs,  smiles,  gives 
a  kiss  on  request.     Repeats  syllables.     Understands  ten  words. 

Sixteenth  Month. — Runs  alone.      Falls  rarely. 

Seventeenth,  Eighteenth,  and  Xineteenth  Months. — Sleeps  ten  hours 
at  a  time.  Associates  words  with  objects  and  movements.  Blows 
horn,  strikes  with  hand  or  foot,  gives  leaves  to  stag,  waters  flowers,  puts 
stick  of  wood  in  stove,  washes  hands,  combs  and  brushes  hair,  and 
other  imitative  movements. 

Twentieth  to  Twenty-fourth  Month. — Marks  with  pencil  on  paper, 
whispers  in  reading  newspaper.  Yery  few  expressions  of  his  are  recog- 
nizable. Executes  orders  with  surprising  accuracy.  Tries  to  sing  and 
beat  time,  and  dance  to  music. 

Twenty-fifth  to  Thirtieth  Month. — Distinguishes  colors  correctly. 
Sentences  of  several  words.  Begins  to  climb  and  jump  and  to  ask 
questions. 

Thirtieth  to  Fortieth  Month. — Goes  upstairs  without  help.  Sen- 
tences correctly  applied.  Clauses  formed.  Words  distinctly  spoken,, 
but  influence  of  dialect  appears.  Questioning  repeated  to  weariness. 
Approximates  manner  of  speech  to  that  of  family  more  and  more. 

By  contrasting  the  mental  development  of  the  supposedly  abnormal 
child  with  these  observations  of  Preyer  upon  normal  development,  it  will 
not  be  difficult  to  appreciate  impairment  of  varying  degree.  The  presence 
of  mere  backwardness  may  not  infrequently,  however,  be  obsen^ed  in  chil- 
dren that  later  develop  normally,  and  it  is  well  to  bear  this  fact  imnind ;. 
but  the  combination  of  backwardness  in  the  development  of  the  sen- 
sations, perceptions,  ideation,  and  speech  with  marked  physical  signs  of 
degeneracy  or  brain  lesion  would  be  naturally  of  the  greatest  importance 
from  the  diagnostic  point  of  view. 

Diagnosis  of  the  Form  and  Nature  of  the  Idiocy. — AMiile  the 
diagnosis  of  the  presence  of  idiocy  is,  as  a  rule,  fairly  easy,  especially 
after  infancy  has  reached  the  stage  of  childhood,  the  diagnosis  of  the 
type  or  kind  of  idiocy  presented  is  often  attended  with  great  difficulty. 
Where  the  cerebral  disorder  or  defect  is  accompanied  by  striking  physi- 
cal peculiarities  or  malformations,  such  as  hydrocephalus,  microceph- 
aly, paralysis,  or  myxedema,  we  are  immediately  in  a  position  to 
classify  the  type.  In  idiocy  associated  with  epilepsy,  too,  we  can  readily 
approximate  the  type,  though  it  must  always  be  remembered  that  there 
are  three  distinctive  ways  in  which  epilepsy  and  idiocy  are  correlated — 
viz.,  paralytic  idiocy  combined  with  epilepsy,  epileptic  idiocy  from  a 
homologous  lesion  not  implicating  the  motor  centers  or  tracts,  and, 
finally,  dementia  in  childhood  depending  upon  the  epilepsy.  The  trau- 
matic class  of  cases  is  recognized  either  by  the  external  evidence  of  in- 
jury to  the  skull  or  by  the  history  of  direct  relation  of  the  psychic 
symptoms  to  the  antecedent  trauma.  The  sensorial  type  of  idiocy  is 
distinguished  by  existing  or  foregone  loss  of  two  or  more  senses,  par- 
ticularly Ijlindness  and  deafness.  The  amaurotic  type  presents  a  char- 
acteristic syndrome — viz.,  flaccid  or  spastic  weakness  or  paralysis  of  the- 


IDIOCY.  883' 

whole  musculature,  diminished  or  exaggerated  tendon-reflexes,  dis- 
tinctive changes  in  the  fundus  leading  to  optic  atrophy,  and  marasmus. 
In  the  majority  of  cases,  then,  we  are  in  a  position  to  determine  readily 
the  form  of  idiocy  presented  by  the  patient  and  to  formulate  an  opinion 
as  to  the  nature  of  the  pathological  process  or  the  condition  underlying 
it ;  but  there  will  still  remain  a  considerable  number  of  cases  in  which 
diagnosis  can  not  be  made  during  life,  either  as  to  the  type  of  idiocy 
before  us  or  as  to  the  character  of  the  process.  Among  such  puzzling 
cases  will  be  those  indistinguishable  from  the  psychoses  of  early  life ; 
idiocy  following  meningeal  hemorrhage  and  meningitis  without  inducing 
either  paralysis  or  epilepsy ;  idiocy  due  to  tuberous  sclerosis,  and  the 
like. 

Diag-nosis  of  the  Degree  of  Idiocy. — It  is  necessary,  for  purposes 
of  medicopedagogical  treatment,  to  comprehend  the  degree  of  idiocy, 
not  only  to  determine  whether  it  is  simple  idiocy,  imbecility,  or  feeble- 
mindedness, but  to  ascertain,  as  far  as  possible,  the  different  shades  of 
each  of  these  ;  and  it  is  useful,  too,  to  watch  the  progress  of  a  case  under 
treatment,  and  to  record  from  time  to  time  the  advance  made  by  the 
patient  and  pupil.  Accordingly,  the  writer  has  drawn  up  what  may  be 
termed  a  species  of  mind  chart,  as  given  opposite.  The  physician  will  be 
familiar  with  the  ordinary  tests  for  common  and  special  sensibilities. 
The  intensity  and  duration  of  attention  may  be  studied,  in  the  same 
connection,  by  methods  which  will  readily  suggest  themselves  in  relation 
to  objects,  colors,  sounds,  smells,  and  tastes,  which  are  utilized  in  such  a 
way  as  to  demonstrate  perception,  the  retention  of  the  perception,  and 
the  duration  of  such  retention.  The  chief  difhculty  will  be  in  deter- 
mining and  recording  the  purely  intellectual  features  of  the  case ;  but 
some  patience  and  perseverance  will  demonstrate  the  ability  and  degree 
of  ability  of  the  patient  to  acquire,  conserve,  associate,  and  produce 
ideas,  concrete  and  abstract ;  to  appreciate  resemblances  and  differences  ; 
to  count,  add,  subtract,  and  divide. 

Prognosis. — As  regards  the  cure  of  idiocy,  there  can  not  be  any 
difference  of  opinion.  There  are  few  cases — indeed,  almost  no  case — in 
which  improvement  to  some  degree  may  not  be  promised  under  proper 
conditions  ;  but  cure  there  is  none.  The  profound  idiot  may  be  regen- 
erated to  some  slight  degree ;  be  made  less  repulsive,  less  offensive,  less 
destructive.  The  imbecile  can  be  taught  cleanliness,  speech,  divers 
occupations.  The  feeble-minded  subject  is  susceptible  of  enormous  im- 
provement. It  is  impossible  in  any  case  to  predict  how  much  advance 
may  be  made  under  the  best  supervision,  but  it  will  be  safe  to  say  that 
the  methods  now  -in  vogue  in  the  training  of  the  idiot  will  surprise  the 
relatives  or  guardians  by  their  efficacy,  and  there  is  no  case  so  unprom- 
ising and  hopeless  as  to  contraindicate  an  attempt  at  improvement. 
Left  to  itself,  even  a  mild  type  of  idiocy  will  not  only  make  no  prog- 
ress, but  will  be  certain  to  degenerate,  to  lapse  into  a  lower  grade. 
Shuttle  worth,  1  in  reviewing  the  results  of  twenty  years'  experience  at 
one  of  the  large  English  institutions,  states  that  of  patients  discharged 

1  Take's  "Dictionary  of  Psych.  Med.,"  ji.  675. 


884 


MENTAL  DISEASES. 


Mind  Chart. 


Name Age Sex 

Constitution  (feeble,  fair,  robust,  or  obese) 

Form  of  idiocy Degree  of  idiocy 

Paralysis,  deformity,  or  morbid  movements 

Eight-  or  left-handed Temperament  (cheerful,  gloomy,  restless, 

sluggish,  etc. ) 


Sense 
defects. 

Sight. 

Hearing. 

Taste. 

Smell. 

Tactile 
and  pain. 

Muscu- 
lar. 

Ther- 
mic. 

Intensity 
and  duration 
of  attention. 

Instincts. 

Hunger. 

Self-pres- 
ervation. 

Sleep. 

Voluntary 
move- 
ments ; 
play. 

Sexual. 

Imita- 
tion. 

Morals  and 
Habits. 

Tidiness. 

Destruc- 
tiveness. 

Human- 
ity. 

Veracity. 

Polite- 
ness. 

Obedi- 
ence. 

Sentiments. 

Pleasure 
and  pain. 

Affec- 
tion. 

Fear. 

Anger. 

Acquisi- 
tiveness. 

Shame. 

Curios- 
ity and 
astonish 
ment. 

Language. 

Speech. 

Reading. 

Writing. 

Gesture. 

Drawing. 

Intellect. 

Ideas. 

Memory. 

A  ssocia- 
tion  of 
ideas. 

Reason. 

Judg- 
ment. 

Will. 

Arith- 
metic. 

Special  aptitudes. 


IDIOCY.  885 

therefrom  after  full  training,  10  percent,  became  self-supporting,  another 
10  per  cent,  might  have  become  so  had  they  obtained  suitable  situations, 
and  about  20  per  cent,  were  reported  as  useful  to  their  friends  at  home. 
This  bears  out  the  earlier  estimate  of  Seguin,  who  said  that  "  more  than 
40  per  cent,  have  become  capable  of  the  ordinary  transactions  of  life 
under  friendly  control,  of  understanding  moral  and  social  abstractions, 
of  working  like  two-thirds  of  a  man  ;  and  25  to  30  per  cent,  come 
nearer  and  nearer  the  standard  of  manhood,  until  some  of  them  will  defy 
the  scrutiny  of  good  judges,  when  compared  with  ordinary  young  men 
and  women." 

There  are  certain  features  in  connection  with  the  different  types  of 
idiocy  which  are  helpful  in  forming  our  opinion  as  to  the  probable 
future  of  a  patient.  For  instance,  it  may  be  taken  as  an  axiom  that 
the  greater  the  defect  or  injury  of  the  brain,  the  profound er  will  be  the 
mental  impairment  and  the  more  difficult  will  be  the  labor  of  bringing 
about  an  amelioration  of  the  condition.  The  earlier,  too,  that  the  brain 
is  hampered  in  its  development,  the  worse,  as  a  rule,  is  the  prognosis. 
This  holds  good  for  every  form  of  idiocy.  Hence  the  outlook  for  the 
congenital  types  is  less  promising  than  that  for  the  acquired,  and  for 
idiocy  acquired  in  the  first  year  less  than  that  for  idiocy  acquired  in  the 
second.  Some  of  the  prognostic  indications  of  the  special  forms  will 
be  discussed  under  their  respective  captions ;  but,  in  general,  it  may 
be  assumed  that  microcephalic  idiocy  and  congenital  hydrocephalic 
and  paralytic  idiocy  will  be  benefited  least  among  the  types  of  idiocy 
discussed,  and  always  in  proportion  to  the  intensity  of  the  morbid  pro- 
cess. The  sensorial,  traumatic,  and  myxedematous  forms  are,  ceteris 
paribus,  among  the  most  promising.  The  amaurotic  form  is  generally 
fatal.  Idiots  with  special  aptitudes,  or  idiots  savants,  tend  to  early 
psychic  degeneration.  Idiots  that  are  extremely  restless,  as  shown  by 
incessant  motion  of  the  hands,  arms,  head,  trunk,  or  by  constant  walk- 
ing, are  generally  among  the  most  intractable,  because  of  the  difficulty 
of  fixing  their  attention. 

Although  there  is  scarcely  ever  to  be  encountered  an  idiot  in  whom 
improvement  of  some  kind  can  not  be  brought  about  by  assiduous  cul- 
tivation of  whatever  residual  faculties  and  functions  he  possesses,  it  is 
practically  necessary  to  classify  idiots  into  teachable  and  unteachable. 
It  is  practically  so  because  a  majority  of  these  defectives  are  found 
among  the  poor,  who  can  not  command  all  that  the  world  affords  in  the 
way  of  treatment,  care,  and  training.  Xor  could  the  commonwealth 
assume  the  enormous  task  of  doing  the  best  for  all  its  idiot  charges.  No 
community  could  possibly  be  repaid  for  any  such  undertaking,  because 
the  idiots  classified  by  public  authorities  as  unteachable  are  not  sus- 
ceptible of  such  development  as  would  satisfy  the  tax-payers'  right  to 
ask  the  utility  of  the  expenditure.  It  is  only  with  private  families  that 
anxious  parental  solicitude  will  and  can  demand  that  medicopedagog- 
ical  care,  skill,  and  patience  which  can  surmount  almost  insuperable 
difficulties  in  the  education  of  profound  idiots.  Practically,  therefore, 
we  find  that  there  is  a  tendency  to  separate  idiots  into  the  teachable 
and  unteachable ;  a  tendency  in  our  public  institutions  to  exclude  un- 


886  MENTAL  DISEASES. 

promising  cases,  such  as  epileptic  and  paralytic  idiots,  idiots  with  mal- 
formations, marked  cases  of  hydrocephalus  and  microcephaly,  and,  indeed, 
any  patient  requiring  that  particular  and  assiduous  care  which  it  is  not 
in  the  power  of  the  commonwealth  to  give. 

The  prognosis  as  regards  life  depends  directly  upon  the  degree  of 
injury  to  or  defect  of  the  brain.  In  general,  idiots  are  short-lived. 
Diplegic  and  paraplegic  idiots  seldom  attain  the  age  of  twenty  years ; 
hemiplegic  idiots  may  live  much  longer,  though  it  is  infrequent  for 
them  to  attain  the  age  of  forty  and  more  years  ;  hydrocephalics  perish 
still  earlier.  The  same  is  true  of  profound  cases  of  microcephalic  and 
myxedematous  idiocy.  The  rare  form  known  as  amaurotic  idiocy  is 
almost  invariably  fatal  in  infancy. 

General  Treatment  of  Idiocy. — The  treatment  of  the  idiot  in- 
volves the  employment  of  both  physician  and  teacher.  The  adjective 
medicopedagogic  is  made  use  of  to  designate  this  combination  of  medi- 
cal and  educational  features  for  the  care  of  the  defective  classes.  In 
the  union  of  the  two  professions  for  such  purpose  the  educator  occupies 
relatively  the  higher  and  more  important  position.  The  inestimable 
services  of  trained  care-takers  or  nurses  are  not  to  be  overlooked.  That 
patient  will  profit  most  who  receives  the  properly  combined  aid  of  the 
best  physician,  best  teacher,  and  best  nurse.  As  a  rule,  this  fortunate 
concurrence  of  necessary  aids  is  more  apt  to  be  found  in  the  public  or 
private  institution  than  in  the  home ;  but  that  it  is  possible  to  carry  on 
treatment  at  home  under  favorable  circumstances,  is  not  to  be  gainsaid. 

The  methods  of  procedure  formulated  by  Itard,  expanded  by  Seguin, 
and  employed  now-a-days  everywhere  in  private  and  public  institutions 
for  idiots,  with  modifications  induced  by  experience  and  the  progress 
of  educational  science,  are  well  described  in  the  writings  of  Bourneville, 
Shuttleworth,  Ireland,  Down,  and  others.  A  brief  resume  is  given 
below  of  the  process  of 

Education  of  Idiots. — The  educational  treatment  should  begin  as 
soon  as  the  diagnosis  of  defective  intelligence  is  made.  It  need  not  be 
pushed  vigorously  at  too  early  an  age  ;  but  infancy,  when  the  nervous 
system  is  most  impressionable,  plastic,  and  pliable,  is  the  time  for  easy 
modification  and  the  bringing  out  of  the  rudimentary  psychic  processes 
which  are  the  foundations  for  the  later  conduct,  habits,  intelligence, 
and  speech.  Patients  are  admitted  to  the  Bicetre  and  Salpetriere  at 
the  age  of  two  years  and  over. 

In  order  to  understand  the  methods  of  pedagogic  treatment  of  idiocy, 
let  us  imagine  an  infant  brought  before  us  afflicted  with  a  profound  degree 
of  idiocy — i  e.,  one  showing  little  or  no  attention,  unable  to  walk,  to  use 
its  hands  or  to  speak,  and  uncleanly  in  habits.  In  undertaking  a  case 
of  this  kind  the  process  of  education  is  pursued  with  the  following  dis- 
tinct purposes  in  view  : 

1 .  To  develop  the  attention  and  sharpen  the  five  senses. 

2.  To  develop  coordinated  movements  and  strengthen  the  muscles. 

(a)  To  teach  to  walk. 

(b)  To  teach  use  of  the  hands. 

3.  To  inculcate  habits  of  cleanliness  in  person  and  dress. 


IDIOCY.  887 

4.  To  teach  the  patient  the  use  of  language. 

5.  To  arouse  the  intellect  by  inculcating  ideas  of  length,  weight,  surface,  solids, 

form,  number. 

6.  Finally,  to  carry  the  education  higher,  by  means  of  studies  in  natural  history  and 

all  sorts  of  manual  and  industrial  and  moral  training. 

Naturally,  some  of  these  purposes  are  attaiued  at  the  same  time  to 
a  considerable  degree  by  some  one  process  employed  in  education. 
Thus,  when  a  light  bean-bag  is  thrown  at  the  face  of  our  patient,  the 
attention  and  sensibility  may  be  so  feeble  that  it  is  not  noticed  at  first. 
By  frequent  repetition  attention  is  developed,  sensibility  becomes  more 
acute,  a  reflex  movement  to  ward  off  the  missile  is  aroused,  and  gradu- 
ally, by  successive  stages,  the  patient  learns  to  catch  the  bag,  to  throw 
it  back,  and,  finally,  to  go  through  a  simple  drill  with  it,  accompanied 
by  music.  This  single  experiment  then  improves  the  attention  and 
several  of  the  senses,  and  aids  in  developing  coordination  and  strength 
of  the  muscles. 

Attention. — The  degree  of  attention  is,  in  the  idiot,  an  indication 
of  the  degree  of  idiocy.  To  a  certain  extent  the  degree  of  attention 
noted  is  of  valtie  in  prognosis ;  for,  if  the  attention  can  not  be  aroused 
at  all,  no  progress  in  education  can  be  made.  Thus  the  first  step  in 
our  process  of  education  must  be  the  employment  of  methods  of  excit- 
ing attention.  The  most  useful  are  such  as  appeal  to  cutaneous  sensi- 
bility, to  the  eye,  and  to  the  ear.  But  even  if  these  are  in  abeyance, 
the  other  senses  aiford  useful  avenues  of  approach  to  the  nervous 
centers.  Pricking,  tickling,  light  blows,  hot  and  cold  articles,  etc., 
may  be  used  to  attract  attention  through  the  skin.  Colored  balls, 
brilliant  pieces  of  cloth,  a  ray  of  light  in  a  dark  room,  the  magic 
lantern,  or  a  spectrum — sttch  things  may  be  variously  and  patiently 
experimented  with  to  fix  the  attention  of  the  eye,  A  loud  call,  a  bell, 
music,  a  gong,  or  even  a  pistol  shot  sometimes,  are  devices  for  exciting 
the  attention  of  the  ear.  Not  infrequently  months  of  patient  experi- 
ment must  be  traversed  before  we  are  rewarded  for  our  labors. 

Education  of  the  Sense  of  Touch. — The  methods  in  vogue  for 
developing  the  sense  of  touch  generally  aid  at  the  same  time  the  co5rdi- 
nation  of  muscular  movements  ;  hence  in  actual  practice  the  education 
of  the  hand  and  touch  and  also  of  the  eye  proceed  more  or  less  simul- 
taneously. 

The  idea  of  temperature  is  developed  by  plunging  the  hand  into  cold, 
tepid,  or  warm  water,  or  by  the  application  of  bottles  containing  water 
at  different  temperatures. 

The  sense  of  smoothness  or  roughness  of  stirface  is  inctilcated  by 
passing  the  finger-tips  over  a  board,  one-half  of  which  is  covered  with 
velvet,  the  other  half  roughened  like  a  grater.  Pieces  of  sttiff  of  vary- 
ing degrees  of  roughness  or  smoothness  are  also  made  use  of.  The 
softness  and  hardness  of  objects  are  taught  by  the  handling  of  different 
objects,  such  as  hard  balls  or  cushions. 

The  child  is  taught  to  button  by  means  of  two  bands  of  cloth,  one 
with  large  buttons  and  the  other  with  large  button-holes  ;  to  lace  up  a 
shoe,  by  means  of  a  shoe  with  eyelets  a  centimeter  in  diameter,  and 


888  MENTAL  DISEASES. 

alternately  hemmed  with  red  and  blue  leather ;  to  tie  knots,  with  the 
aid  of  a  pad  upon  which  are  spread  strings  of  divers  colors. 

Stringing  beads  and  buttons,  sticking  pins  into  a  pincushion  covered 
with  dotted  stuif,  and  the  use  of  the  size-board  and  form-board  are 
useful  means  of  developing  tactile  sense,  educating  the  eye,  and  bringing 
out  some  of  the  faculty  of  calculation. 

The  Education  of  the  Bye. — After  the  physician  has  remedied  any 
existing  visual  defects,  it  becomes  the  duty  of  the  instructor  to  interest 
the  restless  and  inattentive  eye.  As  already  mentioned,  the  attention  is 
aroused  by  glittering  and  striking  objects,  and,  once  the  gaze  is  captured, 
the  latent  sense  may  be  drawn  out  by  many  devices  familiar  to  the 
kindergartner  and  teacher.  Particolored  balls,  variegated  shapes  and 
colors  of  blocks,  spheres,  squares,  cubes,  illuminated  pictures,  gaudy 
stuffs,  the  spectrum,  the  kaleidoscope — all  of  these  play  a  role  in  the 
education  of  the  vision  of  the  defective  pupil.  The  matching  of 
ribbons,  wools,  or  cards,  and  the  discrimination  of  forms  of  blocks,  are 
methods  of  aiding  the  higher  development  of  the  visual  sense.  The 
size-  and  form-boards  already  alluded  to,  and  the  use  of  graduated  rods 
to  be  placed  by  the  pupil  in  step-like  rows,  are  excellent  adjuncts. 
Later  on  come  into  play  various  games, — dominoes,  ball,  croquet,  mar- 
bles, bean-bag,  hoops,  tennis,  skipping,  battledore  and  shuttlecock,  quoits, 
golf,  and  the  like, — in  the  employment  of  all  of  which  not  only  is  the 
vision  stimulated  and  improved,  but  there  is  a  gain  in  manual  dexterity, 
and  an  associated  development  of  some  of  the  psychic  functions.  The 
teacher  acquires  a  special  tact  in  leading  the  pupil  to  concentrate  his 
mind  upon  what  is  being  done,  and  in  making  use  of  the  instinct  of 
imitation,  so  that  the  child  endeavors  to  do  as  the  other  pupils  are  doing 
or  to  follow  the  movements  of  the  instructor. 

Education  of  the  Sense  of  Hearing. — After  the  physician  has 
made  sure  that  defective  hearing  is  due  rather  to  want  of  attention  than 
to  any  of  the  many  causes  of  deafness,  the  teacher  experiments  upon 
the  sense  with  sounds  of  various  kinds — gongs,  bells,  speech,  instru- 
mental music,  and  songs — and  by  some  one  of  these  means  the  ear  will 
at  last  be  reached  and  kept  open  until  it  becomes  an  avenue  for  im- 
pressions from  the  environment  to  travel  to  the  brain  for  registration  and 
the  rousing  of  new  cerebral  activities.  This  organ  in  the  defective  is 
often  especially  alive  to  the  influences  of  melody  and  harmony,  to  songs 
and  jingles  and  rhymes.  Music  is  an  efficient  aid  in  the  various  drills 
and  games  made  use  of  later  on  in  the  child's  mental  development. 

Education  of  the  Taste  and  Smell. — While  these  senses  have 
not  the  importance  of  the  three  just  described,  it  is  still  useful  to 
stimulate  and  develop  them  as  far  as  possible.  The  child  can  be  taught 
to  discriminate  between  the  simple  taste  sensations — salt,  sweet,  bitter, 
and  sour — by  means  of  solutions  of  salt,  sugar,  quinin,  and  citric  acid, 
and  between  odors  that  are  noisome  and  odors  that  are  pleasant  by 
means  of  tinctures  of  asafetida,  cloves,  and  musk,  and  divers  perfumes. 
Later,  he  learns  to  distinguish  flavors,  and  to  associate  what  is  good 
and  useful  with  pleasant,  and  what  is  hurtful  with  noxious  tastes  and 
smells. 


IDIOCY.  889 

Teaching-  to  Walk. — A  course  of  light  massage  of  the  lower  ex- 
tremities, together  with  exercise  of  the  joints  in  flexion  and  extension, 
is  undertaken  for  the  purpose  of  developing  suppleness  and  strength  and 
improving  the  nutrition.  The  child  is  then  regularly  placed  in  a  swing 
constructed  for  tiie  purpose,  with  a  vertical  board  in  front  in  such  a 
position  as  to  receive  the  advancing  feet  of  the  child  as  it  moves  to  and 
fro.  The  impact  of  the  feet  upon  the  board,  with  the  backward  swing 
caused  thereby,  iu  the  course  of  time  gives  the  child  a  sort  of  pleasure, 
and  awakes  in  it  a  sense  of  the  dependence  of  its  movement  upon  the 
varying  pressure  and  impact  of  its  feet.  It  is  not  long  before  the  child 
is  enabled  to  use  its  legs  with  considerable  ease  and  skill  in  the  exercise. 
Having  attained  this  stage,  the  child  is  now  frequently  held  upright  on 
its  feet  and  then  placed  between  the  parallel  bars  sustained  by  its  arms, 
in  which  position  it  is  induced  to  make  efforts  at  walking,  at  first  for  a 
few  minutes,  but  with  gradual  increase  of  the  time  of  stay  each  day. 
Then  the  pupil  becomes  quickly  ready  for  a  wheel-chair,  which  is  merely 
a  modification  of  the  principle  of  the  parallel  bars,  the  supports  being 
on  wheels,  so  that  as  the  child  walks  it  moves  the  apparatus  about  with 
it.  Later  on  it  is  taught  to  mount  and  descend  a  stair  by  means  of  a 
short,  stationary  step-ladder.  After  this  the  gait  is  rapidly  improved 
by  a  variety  of  exercises,  drills,  simple  dances,  and  the  like. 

Education  of  the  Hands. — Even  though  the  motions  of  the  hands 
be  incoordinate  and  without  force,  though  the  infant  may  be  unable  to 
do  anything  for  itself,  even  to  grasp  an  object  or  to  oppose  the  thumb 
to  the  fingers,  there  are  many  methods  of  overcoming  such  defects  and 
developing  the  normal  power  and  usefulness  of  the  hands.  Among  these 
is  the  employment  of  the  parallel  swinging-ladders  and  rings.  At  first 
the  child's  hands  are  applied  to  the  rounds  and  held  there  by  the  teacher 
during  the  execution  of  such  movements  as  standing,  sitting  down, 
raising  the  arms  high  above  the  head,  and  bending  forward  and  back- 
ward, swinging  to  and  fro,  and  so  on. 

As  the  pupil  makes  progress,  the  drill  is  carried  on  with  great  reg- 
ularity and  precision,  accompanied  by  spoken  commands  and  often  with 
music.  In  this  way  not  only  are  the  muscles  strengthened  and  co5rdi- 
nated  and  the  use  of  the  hands  and  feet  perfected,  but  a  familiarity 
with  certain  words  and  ideas  and  their  association  is  created. 

The  use  of  blocks  in  building  up  various  structures,  with  the  subse- 
quent pleasure  of  tumbling  them  down  again,  is  as  useful  to  these  defec- 
tives as  to  normal  infants. 

Finger-exercises  with  the  peg-board,  or  by  means  of  picture-perforat- 
ing, as  practised  in  the  kindergarten,  may  come  into  play  for  the  devel- 
opment of  the  finger  movements  of  the  hand.  Some  of  the  apparatus 
employed  in  educating  the  sense  of  touch  are  equally  valuable  for  train- 
ing the  accurate  movements  of  the  hands. 

Teaching-  Habits  of  Cleanliness  in  Person  and  Dress. — Idiots 
of  every  degree  are  slovenly,  awkward,  negligent,  unless  taught  and 
supervised,  and  the  lower  grades  are  incompetent  to  use  spoon,  knife,  or 
fork,  unable  to  care  for  themselves  in  any  way,  and  continually  drooling, 
sucking  their  fingers,  holding  the  mouth  open,  and  wetting  and  soiling 


890  3IENTAL  DISEASES. 

themselves.  It  is  of  paramount  importance,  then,  in  their  education  to 
make  every  effort  to  overcome  these  deficiencies. 

Such  children  as  are  unable  or  just  learning  to  walk  are  placed  by 
day  in  especially  constructed  chairs,  and  by  night  in  especially  prepared 
beds,  for  purposes  of  cleanliness,  and  must  be  watched  and  raised  at 
certain  hours  by  the  nurses.  It  is  surprising  how  many  will,  by  assidu- 
ous attention,  soon  learn  to  give  some  signal  to  the  care-takers  of  their 
needs,  and  in  the  end  acquire  control  over  themselves  in  this  regard. 
They  learn  to  expect  the  regular  bath,  and  those  who  progress  further 
become  systematic  in  ablutions,  cleansing  the  teeth,  and  all  the  little 
matters  pertaining  to  the  toilet.  At  the  table  they  are  taught  first  the 
use  of  the  spoon,  then  of  the  fork,  and  lastly  of  the  knife.  They  learn 
to  dress  themselves  and  to  make  themselves  neat  and  tidy,  and  ulti- 
mately to  brush  and  arrange  their  clothing,  blacken  their  shoes,  make 
their  beds,  etc.  All  of  this  instruction  requires  time  and  the  utmost 
perseverance  and  patience  on  the  part  of  the  attendants.  By  it  we 
also  train  the  hands,  the  senses,  and  the  intellect. 

To  close  the  mouth  and  prevent  drooling,  faradic  electrization  of  the 
orbicularis  oris  is  employed,  and  the  insertion  of  a  flat  piece  of  wood 
or  a  stick  of  licorice-root  in  the  mouth  is  useful.  The  teeth  need 
careful  looking  over  by  a  dentist  from  time  to  time,  and  daily 
cleansing.  Sucking  of  the  fingers  and  biting  of  the  nails  can  be 
overcome  by  application  of  aloes  and  other  bitter  or  disagreeable 
substances. 

The  Tea.ching-  of  Language. — In  idiots  we  must  begin  our  incul- 
cation of  the  uses  of  language  according  to  the  laws  of  its  evolution  in 
the  normal  child,  first,  however,  correcting  such  defects  in  the  ear, 
mouth,  or  vocal  apparatus  as  are  amenable  to  medical  or  surgical  treat- 
ment. A  child  first  develops  its  auditory  word-center  and  then  the 
motor  speech-center.  These  two  centers,  with  an  association  tract,  are 
the  primitive  basis  of  language  in  the  child.  Often,  in  defective 
children,  a  course  of  gymnastic  exercises  of  the  lips,  tongue,  and  jaw 
will  be  a  necessary  adjunct  to  the  instruction,  and  in  cases  of  deafness 
the  lip-imitation  method  of  education  will  require  to  be  used. 

In  developing  the  motor  speech-center  the  child  begins  by.  repeating: 
the  simplest  Unguals  and  labials,  such  as  "dadda,"  "tatta,"  "mamma," 
"  papa,"  and  "  babba,"  and  these  first  consonants  should  be  employed  in 
the  construction  of  the  new  words  to  be  learned. 

Music  is  an  excellent  auxiliary  in  teaching  the  aiticulation  and  use 
of  words,  and  Shuttleworth  recommends  Elliott's  "  National  Nursery 
Rhymes,"  set  to  pleasing  melodies,  as  particularly  adapted  for  the  pur- 
pose. The  interest  of  the  pupil  is  often  best  secured  and  sustained 
by  the  employment  of  objective  illustrations.  The  naming  of  subjects 
of  pictures,  of  persons  and  things  about  the  room,  of  parts  of  the 
body,  and  the  imitation  of  cries  of  animals,  are  means  of  arousing 
interest. 

After  developing  the  word-hearing  and  the  motor  speech  centers, 
the  visual  and  writing  centers  will  require  education,  and  the  methods 
in  vogue   are  analogous  to   those   of  the   kindergarten.      Bourneville 


IDIOCY.  891 

recommends  the  use,  first,  of  black  letters  twelve  centimeters  high  ;  then 
an  alphabet  with  the  consonants  in  black  and  the  vowels  in  red,  the 
letters  six  centimeters  in  height ;  then  letters  of  ordinary  size  ;  and, 
finally,  the  repetition,  in  chorus,  of  letters  and  words  placed  before  a 
class.  This  collective  exercise,  in  which  imitation  plays  a  great  part, 
contributes  markedly  to  the  development  of  speech.  Figures  are 
employed  in  much  the  same  manner,  and  counting  is  learned  from 
some  of  the  various  apparatus  already  described,  as  well  as  from 
simpler  and  more  interesting  devices,  such  as  the  use  of  the  fingers, 
shells,  marbles,  buttons,  beads,  and  the  abacus.  The  nursery  game  of 
keeping  shop  is  especially  useful  for  developing  the  ideas  of  number, 
weights,  and  values. 

Writing  and  drawing  are  taught  by  means  of  sand-boxes,  blackboard 
exercises,  and,  finally,  drawing-books.  The  knoM'ledge  of  form  is  best 
mculcated  by  modeling  in  clay,  and  by  reproductions  in  clay  or  wood 
of  surface  drawings. 

From  these  primary  lessons  it  is  but  a  step  to 

Manual  and  Industrial  Training*. — When  the  pupil  has  reached  a 
certain  stage  of  mental  development,  every  effort  is  made  to  further 
the  training  to  such  an  extent  as  to  subserve  the  demands  of  health  and 
utility.  Methods  of  manual  and  industrial  education  are  best  furthered 
in  institutions  in  which  every  variety  of  occupation  commensurate  with 
the  individual  needs  and  tastes  of  the  pupils  can  be  satisfactorily  carried 
out.  In  most  existing  institutions  it  is  true  that  the  ideal  system  of 
care  and  development  of  defectives  has  not  yet  been  attained,  but  the 
tendencies  of  the  present  time  are  in  the  right  direction.  The  insti- 
tutions of  the  future  for  all  classes  of  dependents,  for  idiots,  for  the  in- 
sane, and  for  the  inmates  of  prisons  and  reformatories,  will  doubtless  be 
modeled  on  the  colony  plan.  They  will  be  village  settlements  or  com- 
munities wherein  the  chief  industries  will  be  such  as  relate  to  the 
housing,  clothing,  feeding,  etc.,  of  their  inhabitants,  thus  bringing  into 
existence  all  of  the  occupations  which  tend  to  utility  and  economical 
administration.  The  scheme  is  well  exemplified  and  successfully  dem- 
onstrated by  the  evolution  of  the  Craig  Colony  for  Epileptics  at 
Sonyea,  N.  Y,  Were  I  called  upon  to  draw  up  an  outline  of  a  plan  for 
a  colony  for  idiots,  it  would  be  somewhat  as  follows  : 

1.  In  the  first  place,  there  should  be  an  abundance  of  land,  at  least 
an  acre  for  each  inhabitant.  The  site  should  be  selected  with  due 
regard  to  fertility  of  soil  ;  for  agriculture,  stock-raising,  and  gardening 
should  afford  employment  for  the  majority  of  the  pupils. 

2.  Convenience  of  access  to  managers  and  patients  and  their  friends 
is  a  desideratum.    - 

3.  In  the  construction  and  arrangement  of  buildings  the  country- 
village  idea  should  never  be  lost  sight  of,  and  the  farmstead  group — 
the  cottages,  villas,  schools,  shops,  and  so  on — should  be  simple,  inde- 
pendent, homelike,  and  surrounded  by  their  own  little  gardens,  hedges, 
etc.,  in  conformity  with  such  design. 

4.  So  far  as  possible,  each  house  should  constitute  a  home  circle, 
the  number  of  members  being  limited  to  ten  or  fifteen. 


892  MENTAL  DISEASES. 

5.  An  admiuistration  building,  a  small  hospital  for  the  sick,  special 
villas  for  the  infirm,  bed-ridden,  ineducable,  and  disturbed  classes,  a 
gymnasium,  a  library,  a  museum,  and  swimming-  and  rain-bath,  are 
among  the  separate  structures  required  in  addition  to  those  already 
mentioned. 

6.  The  educational  features  of  the  colony  will  be  carried  on  in  ordi- 
nary schools,  Sloyd  schools,  trade  schools,  and  so  on,  and  everything 
that  may  contribute  to  the  furtherance  of  mental  development  should 
be  encouraged.  Thus  the  field  study  of  natural  history  is  one  of  the 
most  satisfactory  means  of  arousing  the  intelligence,  interest,  and  activity 
of  the  pupils.  Trees,  garden  produce,  and  flowers  should  be  labeled 
with  their  names,  botanical  and  zoological  gardens  should  be  estab- 
lished, and  the  collection  of  rocks,  leaves,  plants,  insects,  birds,  etc., 
made  a  part  of  the  system. 

7.  In  developing  the  industries  of  the  colony,  such  should  first  be 
instituted  as  will  serve  economical  purposes.  The  aim  should  be  to 
produce  most  of  the  foodstuffs  required,  to  carry  on  domestic  work,  to 
make  and  mend  the  wearing  apparel,  to  accomplish  ordinary  repairs,  to 
construct  new  buildings,  and  to  fashion  the  furniture. 

8.  The  whole  scheme  requires  to  be  under  medical  supervision, 
and  the  scientific  aspects  of  the  community  thus  created  should  be 
kept  continually  in  mind.  This  necessitates  the  establishment  of 
psychological  and  pathological  laboratories  after  the  most  approved  style. 

As  an  instance  of  what  species  of  work  may  be  done  by  defectives 
in  institutions,  Bourneville's  statistics  of  occupations  at  Bicetre  for 
1897  show  that  there  were  187  children  employed  in  the  various  shops 
and  workrooms,  among  them  being  :  10  brushmakers,  24  carpenters,  9 
printers,  14  locksmiths,  51  tailors,  28  shoemakers,  and  14  straw-  and 
cane-workers.  The  hemiplegics  work  exclusively  at  sewing,  and  the 
blind  with  straw  and  cane.  The  colony  plan,  however,  would  insure  a 
greater  amount  of  healthier  work  out  of  doors  than  is  possible  at  such 
a  place  as  Bicetre,  and  would  be  more  remunerative  to  the  administration. 

Moral  Training  and  Discipline. — Much  as  the  inculcation  of 
moral  ideas  is  needed  for  normal  children,  defectives  require  even 
more  attention  in  this  respect ;  for  in  them  the  abrogation  of  higher  in- 
telligence is  associated  naturally  with  feeble  inhibitive  power.  Thus 
they  easily  give  way  to  the  lower  instincts,  and  are  prone  to  acquire 
vicious  habits  of  conduct  and  speech.  In  some  cases  the  moral  obliquity 
is  so  great  that  it  constitutes  the  so-called  moral  imbecility,  and  little  can 
be  accomplished  for  their  improvement.  But  the  majority  of  defectives 
are  susceptible  to  the  influences  of  a  good  environment  and  moral  disci- 
pline. Imitation  of  the  teacher  and  of  playmates  and  schoolmates  counts 
for  much  with  them.  The  judicious  instructor  and  care-taker  can,  by 
firm  and  kindly  guidance,  accomplish  great  good  in  this  respect,  and  it 
should  always  be  kindly  guidance,  never  coercion.  There  is,  however, 
merit  in  the  employment  of  a  system  of  rewards  and  punishments 
adapted  to  the  idiosyncrasies  of  the  different  pupils.  A  few  words  of 
encouragement  or  praise,  or  trifling  compensations  in  the  way  of  extra 
allowances  of  food,  delicacies,  recreations,  or  small  wages,  appeal  dis- 


IDIOCY.  893 

tinctly  to  some  ;  while  words  of  disap})roval,  the  curtailing  of  things 
pleasant  to  the  palate,  the  deprivation  of  some  anticipated  pleasure,  and 
so  on,  have  especial  influence  with  others.  It  is  a  good  plan  to  dis- 
tinguish the  pupils  for  meritorious  conduct  and  industrial  accomplish- 
ments by  distinctive  dress,  thus  appealing  to  their  ambitions.  It  is  well 
to  establish  three  or  four  grades  to  be  thus  distinctively  recognized,  for 
nothing  is  more  human  than  the  instinct  to  appear  well  to  others,  to  be 
amono'  the  best-dressed.  The  instinctive  desire  of  the  savage  for  orna- 
ment  is  no  stronger  than  that  of  the  most  civilized  being  for  good 
clothes.  The  mentally  feeble  are  no  strangers  to  this  feeling,  and  their 
good  conduct  can  be  enhanced  and  maintained  by  promotion  to  a  better 
clothed  division,  and  their  shortcomings  well  punished  by  reduction  to  a 
lower  rank.  Corporal  punishment  is  both  necessary  and  useful  in  ex- 
treme cases  with  vicious  tendencies,  but  should  be  a  last  resort  even  here. 

By  the  means  just  described,  and  by  other  devices  that  will  sug- 
gest themselves  to  the  wise  and  tactful  person  whom  we  suppose  to  be 
intrusted  with  their  care,  these  unfortunates  may  be  taught  obedience, 
perseverance,  responsibility,  and  regard  for  the  rights  of  others,  and  be  im- 
bued with  some  knowledge  of  the  great  laws  of  justice,  beauty,  goodness, 
and  religion  which  rule  the  ideal  world  of  humankind. 

Physical  Culture. — The  tendency  to  incorrectness  of  gesture  and 
bearing,  the  great  lack  of  strength  and  grace,  among  idiots,  must  be 
overcome  by  systematic  education  of  the  muscles.  There  should  be 
courses  of  gymnastic  exercises  and  drills,  with  song  and  instrumental 
accompaniments.  The  drills  may  be  made  with  wands,  light  dumb- 
bells, etc.  Military  drill  is  excellent  for  both  girls  and  boys.  Dancing 
is  beneficial  to  both  mind  and  body.  Bourneville  has  introduced 
fencing  at  Bicetre,  but  does  not  speak  of  it  with  enthusiasm. 

The  Medical  Treatment  of  Idiots. — The  medical  and  surgical 
treatment  of  the  different  forms  of  idiocy  is  thoroughly  discussed  under 
their  several  chapters  in  this  book,  and  it  is  intended  here  to  refer  only 
to  the  treatment  of  certain  general  conditions  met  with  in  all  classes  and 
grades  of  idiocy.  Among  such  conditions  are  some  that  relate  to  hy- 
giene, and  others  that  pertain  to  bad  habits,  general  diseases,  and  the  like. 

Hydrotherapy. — The  rain-bath  is  nowadays  considered  a  necessary 
adjunct  to  all  public  institutions,  because  of  expedition  in  its  use  and 
perfect  cleanliness.  Such  baths  should  be  the  daily  morning  rule  of 
defectives.  The  skin  is  kept  in  a  hygienic  state,  the  circulation  is 
stimulated,  and  general  nutrition  is  improved  by  the  mornhig  bath.  In 
lethargic  or  apathetic  states  the  cold  spinal  douche  is  beneficial,  while 
in  very  restless  patients  the  prolonged  warm  bath  and  wet-packs  at 
night  often  materially  aid  in  overcoming  the  condition. 

Clothing-. — One  of  the  noteworthy  stigmata  of  degeneration  common 
to  all  classes  of  idiocy  is  a  diminished  resistance  to  external  influences 
and  diseases.  They  catch  cold  easily.  Tuberculosis  and  other  lung  dis- 
orders account  for  nearly  seventy-five  per  cent,  of  the  mortality  among 
them.  Diarrheas  are  common.  Hence  it  is  important  that,  among 
other  thiuffs,  considerable  attention  should  be  ffiven  to  clothiup;.  Woolen 
undergarments  of  warm  and  lioht  texture  should  be  the  rule.     The 


894  MENTAL   DISEASES. 

outer  clothing  should  be  light,  durable,  neat,  of  prevailing  cuts  and 
styles,  and  none  of  the  clothing  should  in  any  way  impede  or  restrict 
the  free  motions  of  the  limbs  and  trunk. 

Food. — The  dietary  for  this  class  of  defectives  should,  in  my 
opinion,  closely  approximate  that  of  epileptics — i.  e.,  it  should  be  chiefly 
vegetable,  with  the  free  use  of  milk  and  eggs,  and  meat  but  once  daily. 
Simplicity  of  food  and  simple  cooking  are  essential.  The  dietary  need 
not  be  so  elaborate  as,  for  instance,  in  hospitals  or  asylums,  where  acute 
disorders  are  commonly  treated,  and  where  the  percentage  of  cure  is 
expected  to  be  large.  Idiots  are  apt  to  overeat,  and  hence  the  chief 
requisite  is  to  regulate  the  per  capita  allowance  to  just  the  amount 
necessary  to  maintain  a  robust  state  of  physical  health.  Overeating  is 
probably  responsible  for  much  of  the  diarrhea  commonly  observed 
among  these  cases. 

General  Bodily  Health. — Very  common  is  a  condition  of  general 
debility,  which  must  be  met  by  appropriate  tonics,  nutritive  foods, 
special  baths,  massage,  and  regular  exercise.  The  great  mortality  from 
tuberculosis  should  lead  the  physician  to  a  regular  examination  of  the 
viscera  for  symptoms  of  that  disorder.  When  discovered,  the  usual 
precautions-  should  be  taken  to  isolate  the  patient  and  to  build  up  the 
constitution  in  every  way.  Parasitic  and  nervous  skin  diseases  will 
often  need  attention.  The  prevailing  mucous  diarrlieas  are  treated  by 
the  usual  remedies  and  by  careful  regulation  of  the  kind  and  amount  of 
food.  Owing  to  feebleness  of  constitution  and  diminished  resistance  to 
diseases,  especial  danger  attaches  to  acute  infectious  fevers  in  idiots. 

Masturbation. — The  prevalence  of  this  pernicious  habit  among  all 
classes  of  idiots  is  only  too  pronounced.  In  the  lowest  grades  it  is  un- 
common, but  among  the  imbeciles  and  feeble-minded  it  is  one  of  the 
most  intractable  of  conditions.  There  are  few  agents  and  devices 
which  have  not  been  tried,  and  usually  vainly,  to  prevent  the  practice. 
It  is  only  rarely  that  vesication  of  the  genitals,  punishment,  mechanical 
restraint  of  the  limbs,  and  sedative  drugs  have  any  effect  in  the  treat- 
ment of  defectives.  Indeed,  they  might  usually  as  well  be  left  untried. 
There  have  been  very  few  experiments  of  the  method  of  cure  by  cas- 
tration, for,  naturally,  professional  opinion  is  too  conservative  to  under- 
take, without  long  and  careful  deliberation,  so  radical  a  remedy.  I  know 
of  but  one  institution  wdiere  castration  has  been  apparently  adopted  as 
a  part  of  the  regular  system  of  care  and  treatment.  The  superintendent 
of  the  Winfield,  Kansas,  Asylum  for  Idiots  has  had  between  twenty 
and  thirty  boys  who  were  inveterate  masturbators  subjected  to  castra- 
tion, with  excellent  results.  JN^ot  only  were  their  vicious  habits  put  an 
end  to,  but  there  was  marked  physical  improvement  in  all,  and  great 
mental  improvement  in  most,  of  them.  There  would  seem  to  be  no 
reasonable  objection  to  operative  j^rocedure  in  such  cases,  though,  per- 
haps, it  is  hardly  necessary  to  go  so  far  as  castration.  Ligature  of  the 
vas  deferens,  or  possibly  section  of  some  branch  of  the  pudic  nerve, 
might  serve  as  well.  At  any  rate,  some  method  of  this  kind  is  well 
worthy  of  consideration,  though  the  ultimate  decision  of  the  profession 
as  to  its  utility  and  propriety  has  yet  to  be  learned. 


INDEX. 


Abdominal  reflex  .  34 
Abscess  of  brain,  235 
diaguosis  of,  238 
eucj'sted,  236 
etiologj'  of,  235 
headache  in,  238 
invasion  stage  of,  237 
latent  period  of,  237 
multiple,  236 
paralytic  stage  of.  237 
pathological  anatomy  of,  236 
prognosis  of,  239 
remission  stage  of,  237 
symptoms  of,  237 
treatment  of,  239 
Accessor}',    spinal,    143.     See  also  Spinal 

accessory  nerve. 
Accommodation,  errors  of,  importance  of, 
62 
in  multiple  neuritis,  313 
Acetonuria  in  insanity,  753 
Achilles  tendon-reflex,  36 
Achromatopsia,  64 
Aconite  in  cerebral  hemorrhage,  214 

in  hematomyelia,  351 
Aconitia  of  Dnquesnel  in  neuralgia,  629 
Acrocephalus,  694 
Acromegalia,  482 
course  of,  487 
diagnosis  of,  487 
differential  diagnosis  of,  487 
etiology  of,  482 
forms'of,  487 
morliid  anatomy  of,  483 
prognosis  of,  487 
symptoms  of,  474 
treatment  of,  488 
Acroparesthesia,  511,  637 
Actinomycosis  of  brain,  254 
Actions,  disorders  of,  747 

induced  by  defects  of  memory,  747 
by  disorders  of  emotions,  747 

of  idea-association,  748 
by  sensory  disorders,  747 
Active  electrode,  42 
Acupuncture  in  solatia  neuritis,  303 
Acute   anterior    poliomyelitis,    374.     See 
also  Foliomi/elitis. 
ascending  paralysis,  362.     See  also  Lan- 
dry's paralysis. 
dementia,  806 

infectious   diseases   in   etiology   of    in- 
sanity, 716 
Addison's  keloid,  507 
Adenolipomatosis,  517 
Adiposis  dolorosa,  518 


Adonis  vernalis  in  epilepsy,  801 

Adventitious  neuritis,  279 

Affective  agitation,  748 

Age  in  etiology  of  insanity,  688 

Ageusia,  66 

Agitated  dementia,  803 

Agoraphobia,  745 

Agraphia  with  motor  aphasia,  173 

Alcohol  in  cerebral  hemorrhage,  214 

in  etiology  of  insanity,  713 
Alcoholic  neuritis,  316 

prognosis  of,  321 
Alexia,  99 

Alienation  mentale,  643 
Alimentary  canal,  examination  of,  24 
Allocheiria,  54 
Alternating  insanity,  789 
Amaurotic  family  idiocy,  247 
Amenorrhea  in  insanity,  753 
Amentia,  670 
American  disease,  563 
Amimia,  68,  171 
Amnesia  verbalis,  68 
Amputation  neuroma,  284 
Amusia,  171 

Amyelinic  neuromata,  284 
Amjd  nitrite  in  angina  pectoris,  142 

in  Eaynaud's  disease,  511 
Amylene  hydrate  in  mental  disease,  768 
Amj'otrophic  lateral  sclerosis,   389.      See 

also  Progressive  muscular  atrophy,  spinal. 
Anal  sphincteric  reflex,  36 

reflex,  36 
Analgesia,  54 

in  myelitis,  354 

in  syringomyelia,  385 

in  tabes  dorsalis,  421 
Anemia,  cerebral,  193 

combined  cord-lesions  in,  448 
Anesthesia,  54 

from  lesion  of  anterior  crural  nerve,  296 

from  lesion  of  circumflex  nerve,  288 

from  lesion  of  external  plantar  nerve, 
298 

from  lesions  of  spinal  cord,  336 

from  paralysis  of  sciatic  nerve,  297 

hj'sterical,  56.  576 
distribution  of,  579 
peculiarities  of,  580 

in  mental  disease,  732 

in  syringomyelia,  385 

of  larynx,  136 

relation  of,  to  lesions  of  cord,  31 
to  lesions  of  nerve-trunks,  54 
Aneurysms  of  brain,  254 
Anger,  737 


895 


896 


INDEX. 


Angina  cruris,  512 

pectoris,  141 
hysterical,  595 
Angioma  of  brain,  254 
Angioneurotic  edema,  513 
diagnosis  of,  515 
etiology  of,  513 
prognosis  of,  515 
symptoms  of,  514 
treatment  of,  515 
Angiosclerotic    paroxysmal    myasthenia, 

512 
Anhedonia,  733 
Ankle-clonus,  36 

spurious,  37 
Anodal  closing  contraction,  43 

opening  contraction,  43 
Anodynes  in  neuritis,  283 

in  neuromata,  286 
Anomalies,  dental,  in  insanity,  704 

of  appetite  in  insanity,  712 

of  body  in  insanity,  710 

of  cranium  in  insanity,  692 

of  ear  in  insanity,  705 

of  eyes  in  insanity,  705 

of  genital  organs  in,  insanity,  710 

of  uenito-urinary  function  in  insanity, 
712 

of  instinct  in  insanity,  712 

of  limbs  in  insanity,  710 

of  lips  in  insanity,  704 

of  motor  function  in  insanity,  711 

of  nose  in  insanity,  705 

of  sensory  function  in  insanity,  711 

of  skin  in  insanity,  711 

of  speech  in  insanity,  712 

of  tongue  in  insanity,  704 
Anorexia,  hysterical,  596 
Anterior  horn  of  cord,  effect  of  lesions  of, 
236 

median  artery  of  cord,  329 

roots  of  cord,  effect  of  lesions  of,  346 

spinal  artery,  329 
Antipyretics  in  tubercular  leptomeningi- 
tis, 94 
Antipyrin  in  brain  tumor,  263 

in  chorea,  541 

in  epilepsy,  614 
AntiseiJtics  in  sinus  thrombosis,  232 
Anxiety,  736 

psychosis,  676 
Apathetic  dementia,  803 
Apathy,  737 

from  tumors  in  corpus  callosum,  180 
Ape  hand,  291,  392 
Aphasia,  67,  168,  650 

auditory,  172 

combined,  177 

conduction,  177 

examination  and  testing  of,  67 

graphic  motor,  175 

in  cerebral  hemorrhage,  206 

in  tumor  of  brain,  258 

motor,  172 

handwriting  in,  173 

varieties  of,  169 

visual,  174 


Aphasics,  reeducation  of,  177 
Aphemia,  172 
Aphonia  in  hysteria,  67 
Aphthongia,  147 
Apoplectic  state,  204 

"stroke,"  204 
Apoplexy,  ingravescent,  211 
Appetite,  anomalies  of,  712 
Arachnopia,  71 
Arc  de  cercle,  588 
Argyll-Eobertson  pupil,  32 

in  insanity,  751 
Arm,  nerves  of,  combined  palsies  of,  293 
Arsenic  in  beer,  multiple  neuritis  from, 
304,  314 
in  chorea,  540 
in  multiple  neuritis,  323 
in  neurasthenia,  573 
Arterial  brain  diseases,  191 
Arteries,  acute  degeneration  of,  201 
of  brain,  191 
of  spinal  cord,  329 
Arteriosclerosis,  cerebral,  197 
symptoms  of,  198,  199 
treatment  of,  199 
Arteritis,  cerebral,  196 
syphilitic  cerebral,  469 
of  brain,  200 
symptoms  of,  472 
Artery,  anterior  median,  of  cord,  329 

spinal,  329 
Arthritic  muscular  atroph}',  39,  407 
diagnosis  of,  408 
etiology  of,  407 
morbid  anatomy  of,  408 
pathology  of,  408 
prognosis  of,  408 
symptoms  of,  407 
treatment  of,  408 
Arthritis,  acute,  in  cerebral  hemorrhage, 
206 
diplococcus  of  M'^eichselbaum  in,  78 
relation  of,  to  chorea,  531 
Arthropathies  in  syringomyelia,  386 
Arthropathy,  dystrophic,-  39 

tabetic,  432 
Aschistodactyly,  710 
Associated  movements,  31 

in  infantile  cerebral  palsies,  244 
Association  disease,  610 
Astasia  abasia,  593 
Astereognosis,  50 
Asthenic  bulbar  paralysis,  157 
Asthma,  bronchial,  137 
symptoms  of,  138 
treatment  of,  138 
spasmodic,  137.    See  also  Asthma,  bron- 
chial. 
Asylums  for  insane,  759 
Asymmetrical  palate,  700,  703 
Asymmetry,  facial,  698 
of  skull.'  693 

physiological,  693 
Atavism  in  mental  and  nervous  diseases, 

18  . 

Ataxia,  detection  of,  28,  29 

family,  450.     See  also  Family  ataxia. 


INDEX. 


897 


Ataxia,  Friedreich's,  450.   See  also  Family 
ataxia. 

hereditary  cerebellar,  450 

in  tabes  dorsalis,  417 

locomotor,  progressive,  409.      See  also 
Tahes  dorsalis. 

progressive  spastic,  444 

static,  29 
Ataxic  gait,  417 

handwriting,  29 

paraplegia,  444 
syphilitic,  476 
Atheroma  of  cerebral  vessels,  196 
Atheromatous  arteries  in  etiology  of   in- 
sanity, 717 
Athetoid  movements  in  infantile  cerebral 

palsies,  243 
Athetosis,  30 

in  infantile  cerebral  palsies,  243 

treatment  of,  249 
Atrophia  muscular  is  progressiva  spinalis, 

389 
Atrophy,  arthritic  muscular,  39,  407.  See 
also  Arthritic  muscular  atrop/iij. 

from  lesions  of  spinal  cord,  337 

in  facial  paralysis,  122 

in  multiple  neuritis,  310 

in  myelitis,  354 

in  syringomyelia,  386 

of  optic  nerve,  102 

progressive   muscular,    388.      See   also 
Progressive  muscular  atrophy. 
Atropin  in  etiology  of  insanity,  715 

in  myoclonia,  545 
Attention,  disorders  of,  740 
Attitude,  importance  of,  27 

in  idiopathic  muscular  atrophy,  402 

in  paraplegia,  361 

in  sciatic  neuritis,  400 
Auditory  aphasia,  172 

hyperesthesia,  64,  127,  128 

nerve,  electrical  testing  of,  47 
irritation  of,  127 
paralysis  of,  128 

symptoms  in  cerebellar  disease,  185 
Aurae,  epileptic,  605 
Aural  vertigo,  129 
diagnosis  of,  130 
treatment  of,  131 
Auriculobregmatic  radii,  695,  698 
Autochthonous  idea,  657 
Autohypnosis,  638 
Auto-intoxication  in  etiology  of  insanity, 

713 
Aztec  ear,  707 

Babixski's  toe-sign,  36 

Bacillus  coli  in  leptomeningitis,  78 
tubercle  in  tubercular  meningitis,  91 

Basal  ganglia,  functions  and  lesions  of,  181 

Basedow's  disease,  497.     See  also  Exoph- 
thalmic goiter. 

Basilar  meningitis,    89.     See  also  Lepto- 
meningitis, tubercular. 

Basion,  696 

Batteries  for  electrical  testing,  40 

Beard's  disease,  563 

57 


Bedsore  in  cerebral  hemorrhage,  206 
Beer,  arsenic  in,  multiple  neuritis  from, 

304,  314 
Belladonna  in  epilepsy,  614 

in  exophthalmic  goiter,  506 

in  nocturnal  enuresis,  636 
Bell's  palsy,  119 
Benedikt's  calipers,  696,  697 
Beri-beri,  304,  318 
Betanaphtol,  614 

in  auto-intoxication,  766 

in  epileps}',  801 

in  myelitis,  358 
Bichlorid  of  mercury  in  anterior  myelitis, 
381 
in  Landry's  paralysis,  366 
Binauricular  arc,  695,  698 

diameter,  695,  698 
Blainville  ear,  706 
Blepharospasm  as  a  symptom,  61 
Blindness,  functional,  102 

toxic,  102 
Body,  anomalies  of,  710 
Bones,  testing  sensibility  of,  54 
Brachial  plexus,  lesions  of,  293 

neuritis  of,  294.     See  also  Xeuritis. 
Brachycephalic  head,  693 
Bradycardia,  140 

Brain,   abscess  of,  235.     See  also  Abscess 
of  brain. 

aneurysms  of,  254 

arterial  supply  of,  191 

carcinoma  of,  252 

cysts  of,  253 

disease,  pain  in,  601 

glioma  of,  251 

inflammation  of,  232 

lesions  of,  destructive,  186 
general  considerations  of,  186 
headache  in,  188 
irritative,  186 
vertigo  in,  188 

sarcoma  of,  251 

softening  of,  216 

syphilis  of,  469.    See  also  Syphilis,  cere- 
bral. 

tubercle  of,  250 

tumors   of,    250.     See   also    Tumors  of 
brain. 
syphilitic,  253 
Brandy  in  mania,  752 
Break  of  current,  42 
Bregmatolambdoid  arc,  63,  695 
Bright' s  disease  as  predisposing  to  nervous 

disease,  19 
Brodie's  joints,  582 
Bromid  in  cerebral  softening.  224 

of  potassium  in  tubercular  leptomenin- 
gitis of  children,  94 
Bromids  in  brain  tumor,  263 

in  epileps}',  614 

of  infantile  cerebral  palsy   349 

in  exophthalmic  goiter,  506 

in  mental  disease,  768 

in  multiple  neuritis,  324 

in  myoclonus  epilepsy,  611 

in  paralytic  dementia,  820 


898 


INDEX. 


Bromids  in  senile  dementia,  806 

in  tetanus,  523 
Bronchial  asthma,  137.     See  also  Asthma. 
Brown-Sequard  paralysis,  cord  lesion  in, 

55,  56 
Bruit  in  intracranial  aneurj'sms,  189 
Bulbar  paralysis,  acute,  156 
asthenic,  157 

progressive,   151.     See  also  Polio-en- 
cephalitis inferior  chronica. 
Bulbocavernous  reflex,  429 
Bulimia,  733 

Cachexia,  combined  cord-lesions  in,  448 

strumipriva,  490 
Caffein  in  bi'aiu-tumor,  263 

in  migraine,  619 
Cagot  ear,  708 
Caisson  disease,  366 
etiology  of,  366 
morbid  anatomy  of,  367 
prophylaxis  of,  368 
symptoms  of,  367 
treatment  of,  368 
Calabar  bean  in  tetanus,  523 
Calipers,  696,  697 
Calomel  in  hydrocephalus,  267 

in  leptomenijQgitis,  86 

in  tubercular  leptomeningitis,  94 
Camphor  in  bronchial  asthma,  139 
Cannabis  indica  in  etiology  of   insanity, 
715 
in  Parkinson's  disease,  552 
in  torticollis,  144 
Carcinoma  in  etiologj^  of  insanity,  717 

of  brain,  252 
Cardiac   branches   of    vagus,   diseases   of, 
139 

palpitation,  140 
Cardiopathy,  relation  of,  to  chorea,  531 
Cardiothyroid  exophthalmos,  497 
Case-book,  value  of,  69 
Catatonia,  683 
Catatonic  melancholia,  783 

rigidity,  781 
Cathodal  closing  contraction,  43 
tetanus,  44 

opening  contraction,  43 
Cauda  equina,  lesions  of,  347 
Center  for  ej^e-movements,  163 

for  hearing,  166 

for  larynx,  164 

for  lips,  164 

for  lower  extremities,  164 

for  lower  face  movements,  163 

for  mastication,  164 

for  motor  speech,  164 

for  pharnA'x.  164 

for  smell,'  166 

for  speech,  168 

for  taste,  166 

for  toes,  164 

for  tongue  movement,  163 

for  trunkal  movements,  164 

for  upper  extremities,  164 

for  upper  face  movements,  163 

for  vision,  165 


Centers,  cortical,  162 

relation  of  body  to,  165 
for  word  memories,  168 
motor,  of  cerebral  cortex,  162 
Central  canal  of  cord,  effect  of  lesions  of, 
346 
myelitis,  352 
scotoma,  99 
Cephalalgia,  hysterical,  594 
Cephalic  index,  693 

tetanus,  522 
Cerebellar  hemorrhage,  211 
Cerebellospasmodic  gait,  462 
Cerebellum,  function  of,  183 
lesions  of,  headache  in,  185 
symptoms  of,  183 
vertigo  in,  184 
Cerebral  anemia,  193 
diagnosis  of,  194 
etiology  of,  193 
symptoms  of,  193 
treatment  of,  194 
arteriosclerosis,  197 
arteritis,  196 

syphilitic,  69,  200 
cortex,  cells  of,  161 
latent  lesions  of,  166 
lesions  of,  effects  of,  on  sensation,  56 
localization  in,  159.      See  also  Local- 
ization, cerebral. 
motor  centers  of,  162 
unknown  functions  of,  166 
hemorrhage,  201.     ^ee  al&o  Hemorrhage. 
hyperemia,  194 
diagnosis  of,  195 
etiology  of,  194 
symptoms  of,  195 
lesions  in  tabes  dorsalis,  416 
njeninges,  anatomical  considerations,  71 

diseases  of,  71 
meningitis,  sypliilitic,  469 
palsies  of  children,  240 

causes  attending  birth,  241 
classification  of,  242 
diagnosis  of,  248 
diplegic  cases,  245 
epileptic  attacks  in,  248 
etiology  of,  240 
hemiplegic  cases,  243 
morbid  anatomy  of,  242 
postnatal  causes  of,  241 
prenatal  causes  of,  240 
prognosis  of,  248 
symptoms  of,  242 
treatment  of,  249 
periarteritis,  196 
sinuses,  225 
softening,  216 

abrupt  onset  in,  219 
course  of,  221 
diagnosis  of,  221 
differential  diagnosis  of,  222 
etiology  of,  218 
location  of,  218 
paralytic  state  in,  220 
pathological  anatomy  of,  216 
prognosis  of,  223 


INDEX. 


899 


Cerebral   softening,  progressive  onset  in, 
220 
red,  217 

sensory  disturbances  in,  221 
symptoms  of,  219 
treatment  of,  224 
white,  217 
yellow,  217 
syphilis,  469.  See  also  Sijj)}iiUs,  cerebral. 
veins,  225 

white   matter,  function   of,  in   localiza- 
tion, 179 
Cerebritis,  232 

acute  localized,  232,  234 
etiology  of,  232 
pathological  anatomy  of,  233 
symptoms  of,  234 
treatment  of,  234 
chronic,  235 

from  cerebral  hemorrhage,  206 
syphilitic,  469 
Cerebroma,  253 
Cerebrospinal    meningitis,   77.      See  also 

Leptomeningitis. 
Charcot- Marie  disease,  406 
Charcot's  disease,  389,  395 

joints,  39,  433 
Chemocephalus,  694 
Chiasm,  optic,  lesion  of,  97,  100 
Children,    cerebral   palsies   of,    240.     See 

also  Cerebral  palsies  of  children. 
Chirospasm,  557 

Chloral  hydrate  in  mental  disease,  768 
in  chorea,  540 
in  insomnia,  633 
in  multiple  neuritis,  324 
in  paralytic  dementia,  820 
in  status  epilepticus,  801 
in  tetanus,  523 
Chlorid  of  iron  in  anterior  poliomj'elitis, 
381 
tincture  of ,  in  Landry's  paralysis,  366 
Chloroform  in  angina  pectoris,  142 
in  bronchial  ashma,  139 
in  tetanus,  523 
Cholesteatomata  of  brain,  254 
Chorea,  530 

adult  hereditary,  542 
cardiac  disorders  in,  537 
chronic,  542 
complications  of,  541 
corirascles,  533 
course  of,  538 
diagnosis  of,  539 
electric,  545 
etiology  of,  530 
family,  542 
fibrillary,  544 
forms  of,  538 
general  state  in,  538 
gravidarum,  539 
gravis,  538 
handwriting  in,  536 
Huntingdon's,  542 
limp,  539 

mental  symptoms  of,  536 
minor,  530 


Chorea,  morbid  anatomy  of,  533 
motor  symptoms  of,  534 
of  pregnancy,  5:59 
of  Sydenham,  530 
of  the  aged,  542 
paralytic,  539 
pathogenesis  of,  532 
prognosis  of,  540 
I'elations  of  rheumatism  to,  533 
senile,  544 
symptoms  of,  534 
treatment  of,  540 
Choreoid  movements  in  infantile  cerebral 

palsies,  243 
Choroiditis  in  leptomeningitis,  801 
Chronic  delusional  insanity,  821.   See  also 

Paranoia. 
Chvostek's  sign,  528 
Ciliary  reflex,  32 
Circular  insanity,  789 
course  of,  753 
definition  of,  687,  789 
diagnosis  of,  793 
etiology  of,  789 
maniacal  period  of,  790 
melancholy  iieriod  of,  789 
pathologic  anatomj'  of,  792 
prognosis  of,  794 
symptomatology  of,  789 
treatment  of,  794 
varieties  of,  792 
Circulatory  apparatus,  examination  of,  24 
Circumflex  nerve,  lesions  of,  287 
Claudication  intermittente,  512 
Claustrophobia,  745 
Cleft-palate,  701 
Clonic  convulsions,  31 

spasm,  30 
Clonus,  ankle-,  36 
foot-,  36 
rectus,  36 
wrist,  34 
Cocain  in  etiology  of  insanity,  715 
in  multiple  neuritis,  323 
in  myoclonia,  545 
in  neiiralgia,  629 
in  sciatic  neuritis,  303 
Codein  in  epilepsy,  801 
in  mental  disease,  767 
Colloid  of  silver,  Crede's,  for  leptomenin- 
gitis, 87 
Color-blindness,  64 
Coma,  placid,  from  tumors  in  corpus  callo- 

sum,  180 
Combined  aphasias,  177 

cord-lesions  in  anemias  and  cachexias, 

448 
palsies  of  nerves  of  arm,  293 
sclerosis  of  the  spinal  cord,  444 
course  of,  446 
diagnosis  of,  447 
etiology  of,  444 
morljid  anatomy  of,  445 
prognosis  of,  447 
symptoms  of,  445 
treatment  of,  447 
tabes,  444 


900 


INDEX. 


Commotion  insanity,  718 
Concussion  of  spine,  619 
Conduction  of  aphasias,  177 
Congenital  myxedema,  492 

paramyotonia,  553 
Conjunctivitis  in  facial  paralysis,  122 
Consiiuguinity  of  parents  as  a  predisposing 

cause  of  nervous  disease,  18 
Consonant  production,  table  of,  656 
Constant  current,  test  of,  in  health,  43 
Contraction,  anodal  closing,  43 
opening,  43 

cathodal  closing,  43 
opening,  43 

front-tap,  36 

paradoxical,  36 
Contracture,  30 
Contractures  from  cord-lesions,  34 

in  infantile  cerebral  palsies,  243,  244 

in  multiple  neuritis,  310 

of  hysteria,  591 
Convulsions,  31 

clonic,  31 

general,  31 

in  cerebral  palsies  of  children,  243 

in  leptomeningitis,  81 

in  tubercular  leptomeningitis,  92 

in  tumor  of  brain ,  256 

Jacksonian,  31 

local,  31 

tonic,  31 
Coprolalia,  621,  746 

Cord-lesions,   combined,  in  anemias   and 
cachexias,  448 

cross,  table  of  symptoms  in,  339-345 

horizontal  localization  of,  338 

indiscriminate,  348 

motor  symptoms  of,  334 

paralysis  from,  334 

reflexes  in,  336 

sensory  symptoms  of,  336 

trophic  conditions  in,  337 

vasomotor  disturbance  in,  337 

visceral  symptoms  of,  337 
Cord-substance,  traumatic  lesions  of,  348 
Corona  radiata,  function  of,  179 
Corpora  quadrigemina,  function  of,  182 
lesions  of,  100 
symptoms,  182 

striata,  function  of,  181 
Corpus  callosum,  function  of,  180 
Cortex,  cerebral.     See  Cerebral  cortex. 
Cortical  localization,  motor,  162 
sensory,  165 

paralysis  in  inssanity,  750 
Coughs,  nervous,  137 

Counterirritation  in  combined  sclerosis  of 
cord,  447 

in  Landry's  paralysis,  366 

in  neuritis,  283 

in  sciatic  neuritis,  302 

in  spinal  leptomeningitis,  273 

in  syringomyelia,  388 

in  tabes  dorsalis,  441 
Coxalgia,  hysterical,  593 
Cramp,  30 

writers',  557 


Ciania  progensea,  696 
Cranial  anomalies,  692 

nerves,  affections  of,  in  leptomeningitis, 
81 
lesions  of,  in  tabes  dorsalis,  416 
multiple  paralyses  of,  148 
syphilitic  lesions  of,  466 
Craniocerebral  topography,  166 
Craniometrical  measurements,  695 

table  of,  698 
Cranium,  anomalies  of,  692 

deformities  of,  692 

measurement  of,  695 

phvsiological  asymmetry  of,  693 
Cranks,  821 

Crede's  colloid  of  silver  ointment  for  lep- 
tomeningitis, 87 
Cremasteric  reflex,  36 
Cretinism,  493 

sporadic,  492 
Crises,  gastric,  427 

laryngeal,  430 

nephritic,  429 

pharyngeal,  430 

tabetic,  427 

visceral,  427 
Cross-lesions  of  cord,  table  of  symptoms 

in,  339-345 
Crura  cerebri,  function  of,  182 

results  of  lesions  of,  182 
Crural  nerve,  anterior,  lesions  of,  296 
Curare  in  tetanus,  523     ^ 
Current,  break  of,  42 

make  of,  42 
Cutaneous  areas,   relation   of,   to   spinal- 
cord  segments,  55,  58 

distribution  of  nerves,  52,  53 

sensibility,  electrical  testing  of,  47 
Cyclic  psychosis,  789 
Cyeloplegia,  62 
Cysts  of  brain,  253 

Daltoxism,  64 
Darwin  ear,  707 
Deafness,  diagnosis  of  cause  of,  129 

lesion  causing,  165  ^ 

nervous,  128 

treatment  of,  129 

word-,  128 
Debilitating  diseases  as  predisposing   to 

nervous  disease,  18 
Decubitus  from  trophic  disturbance,  39 
Deformity  from  cerebral  palsies  of  chil- 
dren, 243 
Degeneracy,  stigmata  of,  21 
Degeneration,  reaction  of,  45 

secondary,  of  divided  nerve,  277 

stigmata  of,  690 
Delire  de  negation  generalize,  744 
Delirium  acutum,  675 

inanition,  716 

in  anterior  poliomyelitis,  377 

in  leptomeningitis,  80 

in  multiple  neuritis,  314 

tremens,  687 
Delusion  of  grandeur,  744 

of  negation,  744 


INDEX. 


901 


Delusion  of  persecution,  743 
Delusions,  74'2 

effect  of.  on  actions,  749 
in  paralytic  dementia,  ^15 
systeniatization  of.  74.5 
Dementia.  (j:?o.  <)S-2.  s02 
acute,  ."^Olj 
agitated.  803 
apathetic.  803 
definition  of.  802 
epileptic.  7'J(J 
from  mania,  776 
paralytic.  80-2,  808 
definition  of,  808 
diaj^nosis  of,  817 
duration  and  prognosis  of,  816 
etiology  of,  808 
pathological  anatomy  of,  819 
symptomatology  of,  810 
treatment  of,  820 
paralytica,  649 
precox.  669.  670.  684 
primary,  649,  802,  806 

course  and  prognosis  of,  807 
definition  of,  806 
etiology  of,  806 
pathological  anatomy  of.  807 
symptomatology  of,  806 
treatment  of,  807 
secondary,  649.  686,  802,  803 
course  and  progress  of,  804 
pathological  anatomy  of,  804 
symptomatology  of,  803 
senile.  802,  804 

course  and  prognosis  of,  803 
diagnosis  of.  803 
etiology  of,  802 
pathological  anatomy  of,  806 
symptomatology  of,  802 
treatment  of,  806 
simplex.  670 
terminal,  649 
Denieuza  primitiya,  670 
Depression,  735 
Depressiye  wahusinn,  673 
Derangement  psychosis.  657 
Dermographism  in  hysteria.  598 
Destructiye  brain-lesions,  186 
Destructiyeness   in    insane,    management 

of,  771 
Diabetes  a  predisposing  cause  to  neryous 

disease,  19 
Diagnosis  in  neurology,   importance  and 

difficulty  of,  17 
Diet  in  insanity.  764 

in  leptomeningitis,^ 87 
Diffused  symptoms,  187 
Digitalis  in  epilepsy.  614.  801 
.  in  exophthalmic  goiter.  506 
Digiti  mortui.  510 
Digits,  center  for  moyements  of,  164 
Diphtheric  paralysis,  317 
Diplegia,  28 

in  infantile  cerebral  palsies,  245 
Diplococcus   intercellularis  meningitis  in 
leptomeningitis.  78 
of  Weichselbaum  in  leptomeningitis,  78 


Diplopia.  62 

in  ocular  paralysis,  106 
monocular,  62 
test,  107 
Disea-se,  electrical  tests  in,  45 
Disease-entities,  651 
Disease-process,  653 
DiseavSes  in  etiology  of  in.sanity,  716 
Disorders  of  actions,  747 

of  idea-associations,  738 
Disorientation,  654,  659 
Disseminated  myelitis,  352 

sclerosis,  459.     See  also  Multiple  cerebro- 
spinal sclerosis. 
Disuse,  trophic  disturbance  from,  39 
Diyers'  palsy  or  paralysis,  366 
etiology  of.  366 
morbid  anatomy  of,  367 
symptoms  of,  367 
treatment  of,  368 
Diyision  of  neryes,  377 
Dolichocephalic  heads,  693 
Dome-shaped  palate,  700,  702 
Dominant  idea.  657 
Dreams,  23,  634 
Droop-foot    in     multiple    neuritis,    307, 

308 
Dropped  wrist  in  multiple  neuritis,  309 

in  musculospiral  disease,  289 
Dubini's  disease,  545 
Duboisin  in  epilepsy',  801 
in  mania,  778 
in  mental  disease,  767 
Duchenne-Aran's  disease,  389,  395 
Dura  mater,  71 

hematoma  of,  73 

inflammation  of,  73.     See  also  Pachy- 
meningitis. 
Dynamometer,  hand-,  of  ]Mathieu,  27 
Dysacousma,  64 
Dysesthesia.  54 
Dyspepsia,  neryous,  143 
Dystrophic  arthropathy,  30 

Ear,  anomalies  of,  705 

Aztec,  707 

Blainyille,  706 

Cagot,  708 

Darwin,  707 

insane,  751 

Morel,  706,  707 

Stahl,  No.  1,  706.  707 

Stahl,  No.  2,  707 

Wildermuth,  707,  709 
Echolalia,  67,  170 
Ecstasy,  hysterical.  590 
Ectrodactyly.  610 
Ectromelus.  710 
Edema,  acute  circumscribed,  513 

angioneurotic.  513 

chronic  hereditary,  519 
Education  of  idiots.  879 
Eighth  cranial  nerye,  anatomical  consid- 
erations of,  126 
diseases  of,  126 

nerye.  auditory   branch    of.     See  Audi- 
tory nerve. 


902 


INDEX. 


Eighth  nerve,  vestibular  branch  of.     See 

Vestibular  nerve. 
Elbow,  center  for  movements  of,  16-1 
Elbow-jerk,  33 
Electric  chorea,  545 
Electrical  conditions,  39 

examination    in   polio-encephalitis    in- 
ferior chronica,  155 
testing,  arrangement  of  electrodes  in,  42 
batteries  for,  40,  41 
for  motor  areas  of  brain,  48 
in  disease,  45 

of  cutaneous  sensibility,  47 
of  hearing,  47 
of  taste,  47 
of  vision,  47 
tests  in  health,  43 
Electricity  in  anterior  poliomyelitis,  381 
in  exophtlialmic  goiter,  506 
in  facial  paralysis,  125 
in  family  ataxia,  456 
in  infantile  cerebral  palsies,  249 
in  intermittent  limping,  513 
in  Landry's  paralysis,  366 
in  laryngeal  paralysis,  136 
in  multiple  neuritis,  324 
in  myelitis,  358 
in  neurasthenia,  573 
in  neuritis,  283 

of  brachial  plexus,  296 
in  Raynaud's  disease,  192 
in  sciatic  neuritis,  303 
in  spinal  progressive  muscular  atrophy. 
396 
Electrode,  active,  42 

indifferent,  42 
Electrodes,   arrangement  of,  in  electrical 

testing,  42 
Electrotherapy  in  insanity,  767 
Embolism,  cerebral,  216 
Emotions,  735 

disorders  of,  actions  induced  by,  747 
Empirical   greatest  height  of  head,  695, 

656 
Emprosthotonos  in  cerebellar  disease,  184 
Encephalitis,  acute  hemorrhagic,  234 
diagnosis  of,  235 
eticSogy  of.  234 
morbid  anatomy  of,  234 
symptoms  of,  235 
treatment  of,  235 
chronic.  235 

in  cerebral  softening,  217 
Encephalomalacia.     See  Cerebral  Hofiening. 
Endarteritis  deformans  of  cerebral  vessels, 
,  196 

Enfaaits  ariearre,  494 
Enuresis,  nocturnal,  636 
Epigastric  reflex,  34 
Epilepsia  processiva,  609 
Epilepsy,  602 

attack  of,  605.  See  also  Epileptic  attack. 
auras  of  attacks  of,  605 
complete  convulsioii  of,  606 
diagnosis  of,  611 

differential,  612 
ecstasy  in,  590 


Epilepsy,  etiology  of,  603 
general  state  in,  611 
in  etiology  of  insanity,  717 
inciting  causes  of.  603 
myoclonus,  610 
nocturnal,    608 
pathology  of,  604 

postparoxysmal  phenomena  of,  610 
prodromes  of  attacks  of,  605 
prognosis  of.  612 
status  epilepticus  in.  608 
treatment  of,  613 
vertiginous  attacks  in,  608 
Epileptic  attack.  605 
aurse  of,  605 
cerebral.  606 
motor.  605 
psychic,  606 
sensory.  606 
clonic  period  of.  607 
complete,  606 

in  infantile  cerebral  palsies,  248 
incomplete,  608 
period  of  stertor.  607 
psychic  equivalents  of,  609 
tonic  stage  of,  606 
vertiginous,  608 
dementia,  796 
insanity,  794 
acute  transitory,  797 
chronic,  798 
defined,  649 
diet  in,  801 

moral  treatment  of,  797 
treatment  of,  797 
Epileptics,  psj^chic  degeneration  of,  795 
Epistaxis  after  middle  life,  197 
Erb's  paralysis,  406 
phenomenon,  528 
Ergot  in  acute  spinal  leptomeningitis,  273 
in  caisson  disease,  368 
in  spinal  meningeal  hemorrhage,  276 
in  tabes  dorsalis,  443 
Ergotism,  457 

Eruption  in  leptomeningitis,  82 
Erythronielalgia,  318 
Eserin  in  myoclonia,  545 
Esmarch's  bandage  in  Raynaud's  disease. 

511 
Esophagismus,  133 
Esthesiometer,  50 
Exalgin  in  chorea,  541 
Exaltation,  736 
Examination  of  patients  in  insanity,  754 

in  nervous  diseases,  17 
Exophthalmic  goiter,  497 

cardiovascular  symptoms  of,  500 

course  and  progress  of,  505 

diagnosis  of,  506 

digestive  disturbances  in,  504 

etiology  of,  498 

genital  disturbances  in,  504 

goiter  in,  500 

hemorrhage  in,  503 

mental  disturbances  in,  503 

morbid  anatomy  of.  499 

motor  symptoms  of,  502 


INDEX. 


903 


Exophthalmic  goiter,  muscles  in,  500 

ocular  sj'inptoms  of,  501 

respiratory  changes  in,  504 

secretory  symptoms  of,  503 

skin  in,  504 

symptoms  of,  500 
tables  of,  505 

treatment  of,  500 

vasomotor  symptoms  of,  503 
Exothyropex}",  507 
Extension  symptoms,  186 
Extrapial  hemorrhage,  75 
Eyes,  anomalies  of,  704 
Eye-strain,  influence  of,  62 

Face,  center  for  movements  of,  163 
Facial  asymmetry,  698 

hemiatrophy   from   disease  of   trifacial 

nerve,  115 
length,  695,  698 
nerve,  117 

anatomical  considerations  of,  117 
paralysis  of,    119.      See   also   Facial 

paralysis. 
spasmodic  affections  of,  119 
paralysis,  119 
alternating,  126 
course  of,  122 
diagnosis  of,  123 
double,  122 
nuclear,  125 

peripheral,  etiology  of,  119 
prognosis  of,  124 
supranuclear,  126 
symptoms  of,  120 
treatment  of,  125 
spasm,  119 
Facioscapulohumeral    form   of    muscular 

atrophy,  406 
Falling  sickness,  602 
Family  ataxia,  450 
course  of,  455 
diagnosis  of,  456 
etiology  of,  451 
Friedreich's  form  of,  455 
Marie's  form  of,  455 
morbid  anatomy  of,  452 
prognosis  of,  456 
symptoms  of,  453 
treatment  of,  456 
varieties  of,  455 
chorea,  542 
myotonia,  552 
periodic  paralysis,  554 
tremor,  556 
Faradic  current,  test  with,  in  health,  43. 

44 
Fatigue  neuroses,  556 
Feeble-mindedness,  648 
Fever,  hysterical,  597 
Fibrillar  neuromata.  284 
Fibrillary  chorea,  544 

tremor,  29 
Fibroma  of  brain,  254 
Fibular  joint,  300 

Field  of  vision,  62.     See  also  J'isual  field. 
Fifth  nerve.     See  Trifacial  nerve. 


First  cranial  nerve.     See  Olfactory  nerve. 

Fixed  point,  62 

Flat^headedness.  694 

Flat-roofed  palate,  700,  702 

Flavor,  65 

Flexibilitas  cerea,  741,  748 

Fly-blister  in  leptomeningitis,  86 

Folic,  43 

a  deux,  722 

du  doute,  746 

imposee,  722 

simultanee,  722  x 

Foot,  center  for  movements  of,  164 
Foot-clonus,  36 

Foot-drop  in  multiple  neuritis,  307,  308 
Forced  movements  in  cerebellar  disease, 
185 
in  disease  of  labjTinth,  65 

positions  in  cerebellar  disease,  185 
Forgetfulness  in  multijile  neuritis,  314 
Formes  frustes  in  multiple  aolerosis,  466 
Fourth  nerve,   anatomical  considerations 
of.  104 
effect  of  division  of,  105 
Fowler's  solution  in  chorea,  540 
Friedreich's  ataxia  or  disease,  450.     See 

also  Family  ataxia. 
Frontal  lines,  168 
Front-tap  contraction,  36 
Functional  nervous  diseases,  481 

stigmata  of  degeneracy,  22 
Furor  epilepticus,  737 

Gait,  importance  of.  in  diagnosis,  27 

in  family  ataxia,  453 

in  idiopathic  muscular  atrophy,  403 

in  multiple  neuritis,  307 
sclerosis,  462 

in  Parkinson's  disease,  549 

in  .sciatic  neuritis,  300 

paraplegic,  360 
Galvanic  current,   test  of    muscle  by,  in 

health,  44 
Ganglion  neuroma,  284 
Gastralgia,  142 
Gastric  branches  of  vagus,  diseases  of,  142 

crises,  427 
Gastrodynia,  142 
Gastro-intestinal  disorders  in  etiology  of 

insanity,  717 
General  convulsions,  31 

paralysis  of  the  insane,  649,  808.     See 
also  Paralytic  dementia. 

paresis,    649,    808.     See   also   Paralytic 
dementia. 
Geniculate  bodies,  lesion  of.  100 
Genital    disease  in    etiology  of    insanity, 
717 

organs,  anomalies  of,  710 
Genito-urinary  function,  anomalies  of,  712 

tract,  examination  of.  25 
Giant  swelling,  513 

urticaria,  5l3 
Gigantism,  487 

Girdle  sensation  in  tabes  dorsalis,  421 
Glabellar  point,  167 
Glioma  of  brain.  251 


904 


INDEX. 


Glioma  of  spinal  cord,  368 

Globus,  133 
hystericus,  585 

Glossopharjnigeal  uerve,  anatomical  con- 
siderations of,  132 
diseases  of,  132 

Gluteal  nerve,  lesions  of,  297 
point,  300 

Glj'cosuria  in  insanity,  753 

Goiter,  exophthalmic,  497.     See  also  Ex- 
ophthalmic goiter. 

Gothic  palate,  700 

Gowers'  rule  in  testing  diplopia,  107 

Grandeur,  delusion  of,  744 

Grai)hic-motor  aphasia,  175 

Graphospasmus,  557 

Graves'  disease,  497.     See  also  Exophthal- 
mic goiter. 

Gray  matter  of  cord,  lesions  of,  374 

Habit  spasm,  621 

Habitat,  importance  of,  in  diagnosis,  20 
Habits,  investigation  of,  19 
Hallucinations,  727 

auditory,  in  words,  658 

conditions  in  which  they  occur,  730 

eiiect  of,  on  actions,  747 

examination  for,  729 

of  memorj",  740 

origin  of,  729 
Hallucinatory  agitation,  748 

confusion,  730 

stupor,  730 
Hallucinosis,  acute,  677 
Hamniei'-toe,  298 

in  family  ataxia,  454 
Hand-dynamometer  of  Mathieu,  27 
Handwi'iting,  examination  of,  68 

in  chorea,  536 

in  motor  aphasia,  173 
Harelip,  704 

Hashish  in  etiolog>'  of  insanity.  715 
Head  injuries,  in  etiology  of  insanity,  718 

retraction  of,  in  cerebellar  disease,  185 

tetanus,  522 
Headache  as  cerebral  symptom,  188 

in  brain  abscess,  238" 
lesions,  188 
tumors,  256 

in  cerebral  syphilis,  471 

in  encephalic  syphilis,  474 

in  epilepsy,  606 

in  leptomeningitis,  80 

in  lesions  of  cerebellum,  185 

in  migraine,  616 

in  neurasthenia,  566 

in  pial  hemorrhage,  77 

in  tubercular  leptomeningitis,  91 
meningitis,  91 

in  tumor  of  brain,  256 

lead-cap,  566 

occipital,  in  cerebellar  disease,  185 

sick,  615 
Health,  electrical  tests  in,  43 
Hearing,  affections  of,  127 
in  leptomeningitis,  82 

center  for,  166 


Hearing,  electrical  testing  of,  47 
hallucinations  of,  728 
illusions  of,  731 
in  facial  paralysis,  122 
in  idiocy,  856 
testing  of,  64 
Heart  disease  in  etiology  of  insanity,  717 
Hebephrenic  insanity,  684,  720 
Hebetude  from  tumors  in  corpus  callosum, 

180 
Heel-tendon  reflex,  36 
Hematoma  auris,  751 

of  dura  mater,  73 
Hematomyelia,  348 
diagnosis  of,  350 
etiology  of,  348 
morbid  anatomy  of,  349 
p('ognosis  of,  350 
symptoms  of,  350 
treatment  of,  350 
Hemianesthesia  in  cerebral  hemorrhage, 

206 
Hemianopia,  double  homonymous,  expla- 
nation of  production  of,  98 
explanation  of  production  of,  97 
from  cerebral  hemorrhage,  206 
in  tumor  of  brain,  258 
Hemianopic  pupillarj^  reaction,  99 
Hemiatrophy,  facial,  from  disease  of  tri- 
facial nerve,  115 
Hemicordal  lesion,  effect  of,  on  sensation, 

55.  56 
Hemiplegia,  28.  207 

associated  movements  in,  207 
causes  of,  207 

circulatory  disturbances  in,  209 
complications  of,  209 
contractures  in,  207 
from  cerebral  hemorrhage,  205 
gait  in,  208 
hemianesthesia  in,  209 
hysterical,  592 
in  central  softening,  219 
in  cerebral  palsies  of  children,  243 
position  of  upper  extremity  in,  209 
Hemiplegic  gait,  208 

state,  207.     See  also  HemipAegia. 
Hemorrhage,  cerebellar,  211 
cerebral,  201 

apoplectic  state  in,  204 
clinical  forms  of,  211 
course  of,  210 
diagnosis  of,  212 
differential  diagnosis  of,  212 
etiology  of,  203 
hemiplegia  from,  207 
pathological  anatomy  of,  202 
prognosis  of,  213 
sensory  disturbances  in,  206 
symptoms  of,  204 
treatment  of,  214 
troyjhic  disturbances  in,  206 
extradural  spinal,  274 
extrapial,  75 

into  spinal  cord,  348.     See  also  Hema- 
tomyelia. 
into  tumor  of  brain,  258 


INDEX. 


905 


Hemorrhage,  intrapial,  7(> 
meningeal,  75 
pial,  75 

spinal  meningeal,  274 
diagnosis  of,  275 
ctidlo^iy  of,  274 
ni<)il)i(l  anatomy  of,  275 
prognosis  of,  270 
symptoms  of,  275 
treatment  of,  27(5 
subdural  spinal,  274 
Hereditary  cerebellar  ataxia,  450 
cerebrospinal  syphilis,  477 
degeneracy,  690 
spastic  paraplegia,  456 
prognosis  of,  457 
symptoms  of,  457 
treatment  of,  457 
tropho-edema,  chronic,  519 
Heredity  in  etiology  of  insanity,  689 

neurotic  importance  of,  18 
Herpes  labialis  in  leptomeningitis,  82 
zoster,  324 

degeneration  in  periplieral  nerves  in, 
325 
spinal  cord  in,  325 
diagnosis  of,  326 
distribution  of,  326 
etiology  of,  324 
pathology  of,  325     . 
symptoms  of,  325 
treatment  of,  326 
Herpetiform  morphea,  507 
Heterophoria,  62 
Hiccup,  139 

Hide-boimd  disease,  507 
Hip-roofed  palate,  700,  703 
Horizontal  localization  of  cord-lesions,  338 
Hot-baths  in  combined  sclerosis  of  cord, 
447 
in  leptomeningitis,  86 
in  multiple  neuritis,  323 
in  tubercular  leptomeningitis,  94 
Huntingdon's  chorea,  542 
disease,  542 

diagnosis  of,  543 
etiology  of,  542 
morbid  anatomy  of,  542 
symptoms  of,  543 
Hutchinson's  teeth,  704 
Hydrocephalic  cry,  91 
Hydrocephalus,  263 

acute,    89.      See   also    Leptomeningitis, 

tubevcular. 
course  of,  266 
diagnosis  of,  266 
etiology  of,  264 
external,  264 
internal,  264 
niorlnd  anatomy  of,  264 
prognosis  of,  266 
symptoms  of,  265 
treatment  of,  266 
Hydromyelocele,  372 
Hydrophol)ia,  523 
diagnosis  of,  525 
morbid  anatomy  of,  524 


Hydropholjia,  symptoms  of,  524 

treatment  of,  525 
Hydrotherapy  in  cxoplithalmic  goiter,  506 

in  insanity,  765 
Hyoscin  in  epilepsy,  Hol 

in  etiology  of  in.sanity,  715 

in  mania,  778 

in  mental  disease,  767 

in  myoclonia,  545 

in  Parkinson's  disease,  552 

in  senile  dementia,  806 

in  torticollis,  144 
Hyoseyamin  in  epilepsy,  801 

in  etiology  of  insanity,  715 

in  mania,  778 

in  mental  disease,  767 
Hyperacusis,  127 
Hyperageusia,  66 
Hyperalgesia,  54 

in  mental  disease,  732 

in  tabes  dorsalis,  422 
Hyperemia,  cerebral,  194.     See  also  Cere- 

hral  hyperemia. 
Hyperesthesia,  54 

auditory,  64,  127,  128 

from  lesions  of  spinal  cord,  336 

hysterical,  582 

in  mental  disease,  732 

in  multiple  neuritis,  312 
Hyperhedonia,  733 
Hy]KTmctamorphosis,  658 
Hyperostosis  cranii,  489 
Hyperthyroidation,  498 
Hypertrophies,  localized,  515 

unsymmetrical,  517 
Hyphedonia,  733 
Hypnotism,  638 

in  insanity,  770 

in  treatment  of  hysteria,  601 

methods  of  inducing,  638 

uses  of,  639 
Hypnotizing,  methods  of,  638 
Hypochlorhydria  in  insanity,  752 
Hypochondriacal  melancholia,  780,  783 

paralysis,  750 
Hypochondriasis,  743 

effect  of,  on  actions,  749 
Hypoglossal  nerve,  anatomical  conditions 
of,  146 

paralysis,  147 

spasms,  146 
Hypoglossus,  affections  of,  in  leptomenin- 
gitis, 82 
Hypokinesis,  677 
Hypomania,  668 
Hysteria,  574 

aboulia  in,  584 

accidents  in,  584 

achromatopsia  in,  578 

agraphia  in,  595 

amnesia  in,  583 

anesthesia  in,  576 
distribution  of,  579 
peculiarities  of,  580 

angina  pectoris  in,  595 

anorexia  in,  596 

anuria  in,  596 


906 


INDEX. 


Hj'steria,  aphonia  in,  595 
arc  de  cercle  in,  587,  588 
astasia  abasia  in,  593 
attacks  of  ecstasy  in,  590 

of  sleep  in,  590 
aura  of,  585_ 
cephalalgia  in,  594 
clonic  phase  of,  585 
contractures  of,  591 
cough  in,  593,  595 
course  of,  598 
coxalgia  in,  593 
dermographism  in,  598 
diagnosis  of,  599 
digestive  apparatus  in,  596 
dyschromatopsia  in,  577 
dysphagia  in,  596 
dyspnea  in,  596 
epileptoid  attacks  in,  590 

period  of,  585 
etiology  of,  574 
fever  of,  597 
globus  in,  585,  590 
grand  attack  of,  585 
hearing  in,  577 
hemiplegia  in,  592 
hyperesthesia  in,  582 
impressionability  in,  584 
in  etiology  of  insanity,  718 
modified  attacks  of,  589 
monoplegia  in,  592 
motor  accidents  of,  591 
movements  in,  582 
muscular  atrophy  in,  598 
nodding  spasm  in,  593 
paralysis  of,  591 
period  of  clownisra,  586 

of  delirium,  589 

of  passional  attitudes,  588,  589 
phase  of  contortions  of,  588 

of  grand  movements  of,  588 

of  resolution  of,  586 
prognosis  of,  599 
ptosis  in,  593 

pulmonary  congestion  in,  595 
reflexes  in,  580,'  581,  591 
respiratory  affections  in,  590 
rhythmical  spasms  in,  593 
saltatory  chorea  in,  593 
sensory  accidents  of,  594 
simulation  in,  584 
smell  in,  576 

somnambulic  attacks  in,  590 
spasmogenic  zones  in,  582 
special  senses  in,  576 
spinal  irritability  in,  595 
stigmata  of,  576 

mental,  583 

motor,  582 

sensorj^  576 
symptoms  of,  575 
Hysteria,  syncopal  attacks  of,  590 
taste  in,  576 
tetanic  attacks  in,  590 
tics  in,  594 
tonic  phase  of,  585 
torticollis  in,  592 


Hysteria,  trance  in,  590 

treatment  of,  600 
general,  600 
special,  601 

tremors  in,  594 

trophic  accidents  of,  598 

tympanites  in,  596 

urinary  apparatus  in,  596 

vasomotor  accidents  of,  598 

vertiginous  attacks  in,  590 

visceral  accidents  of,  595 
neuralgias  in,  595 

vision  in,  577 
Hysterical  anesthesia,  56,  576 
distribution  of,  579 
peculiarities  of,  580 

breast,  598 

contractures,  591 

fever,  597 

hyperesthesia,  582 

paral.ysis,  750 

pseudomeuingitis,  594 

tics,  594 

tremors,  594 
Hysterogenic  point  or  zone,  582 
Hysteroneurasthenia,  570,  620 

Ice  in  myelitis,  358 
Ice-bag  in  leptomeningitis,  86 
in  sciatic  neuritis,  302 
in  spinal  leptomeningitis,  273 

meningeal  hemorrhage,  276 
Idea,  autochthonous,  657 
dominant,  657 
of  reference,  657 
Idea-association,  actions  induced  by  dis- 
orders of,  748 
disorders  of,  738 

testing  of,  756  - 

Ideas,  accelerated  flow  of,  740 
defective  evolution  of,  734 
diminished  flow  of,  740 
disorders  of,  733 
imperative,  745 
Idiocy,  amaurotic  family,  247,  802,  845 
attention  in,  858 
civility  and  politeness  in,  862 
classification  of,  845 
clothing  in,  893 

consciousness  and  personality  in,  871 
defined,  845 
destructiveness  in,  862 
diagnosis  of,  879 
education  of  attention  in,  887 

of  eye  in,  888 

of  hands  in,  889 

of  hearing  in,  888 

of  sense  of  touch  in,  887 

of  taste  and  smell  in,  888 
food  in,  894 
general,  etiology  of,  852 

pathological  anatomy  of,  ,871 

symptomatology  of,  855 

treatment  of,  886 
hearing  in,  856 
hydrotherapy  in,  893 
instincts  in,  860 


INDEX. 


907 


Idiocy,  intelligence  in,  H67 

laii,i;ua<ie  in.  .^(Jo 

luaiiual  and  industiial  ti'aining  in,  891 

nuirtturljation  in,  894 

medical  treatment  of,  893 

moral  training  in,  892 

morbid  movements  in,  856 

mnscnlar  sensilnlity  in,  856 

organic  sensations  in,  858 

personality  in.  870 

physical  culture  in,  893 

physiognomy  in,  864 

play  in,  862 

preoccupation  in,  860 

prognosis  of,  883 

psychological  evolution  in,  871 

reflection  in,  860 

i-esponsibility  in,  f^^O,  871 

right-  and  left-handedness  in,  857 

sentiments  in,  862 

sight  in,  855 

smell  in,  856 

special  aptitudes  in,  861 

tactile  pain  in,  856 

taste  in,  856 

teaching  of  cleanliness  in,  889 
language  in,  890 
to  walk  in,  889 

thermic  sensibility  in,  856 

voluntary  movements  in,  858 

will  in,  870 
Idiopathic  muscular  spasm,  37 

progressive  muscular  atrophy,  397.    See 
also  Fiocfressice  muscular  atrophy. 
Idiots,  education  of,  886 

savants,  852 
Iliac  point,  300 

Illness,  the  examination  of,  20 
Illusions,  731 

origin  of,  732 
Imbecility  defined,  648 
Imitation  in  etiology  of  insanity,  722 
Imperative  ideas,  745 
Inanition  delirium,  716 
Incoherence,  741 
Incontinence,  urinary,  23 
Incoordination,  detection  of,  28 
Incubus,  635 

Indicanuria  in  insanity,  753 
Indifferent  electrode,  42 
Indiscriminate  cord-lesions,  348 
Infantile  cerebral  palsies,  240.     See  also 

Cerebral  palsies  of  children. 
Infantilism,  494 
Infection  neuroses,  521 
Infective  sinus  thrombosis,  228.     See  also 

Sinus  thrombosis. 
Inflammation  of  brain,  232 

of  nerves,  279.     See  Neuritis. 
Inflammatory  sinus  thrombosis,  228 
Ingravescent  apoplexy,  211 
Inherited  syphilis  as  a  predisposing  cause 

to  nervous  disease,  18 
Insane,  asylums  for,  707 

ear,  751 

isolation  of,  762 

moral  treatment  of,  769 


Insanity-,  643 

accompanying  pliysical  di.seases  of,  749 
acute,  treatment  of,  763 
age  in,  688 

alcohol  in  etiology  of,  713 
alternating,  789 

chronic  delusional,  821.     See  also  Par- 
anoia. 
circular,  789 

defined,  649 
classification  of,  645 
commotion,  718 
course  of,  757 
definition  of,  643 
diagnosis  of,  754 
diet  in,  764 

disorders  of  sensation  in,  727 
drugs  in,  767 
electrotherapy  in.  767 
epileptic,  649,  794 

acute  transitory,  797 

chronic,  798 

treatment  of,  799 
etiology  of,  acute  infectious  diseases  in, 
716 

atheromatous  arteries  in,  717 

atropin  in,  715 

carcinoma  in,  717 

cocain  in,  715 

epilepsy  in,  717 

gastro-intestinal  disorders  in,  717 

genital  disease  in,  717 

hashish  in,  715 

head  injuries  in,  718 

heart  disease  in,  717 

hysteria  in,  718 

irritation  in,  722 

menopause  in,  721 

metallic  poisons  in,  715 

morphin  in,  714 

nephritis  in,  717 

nervous  exhaustion  in,  719 

organic  nervous  diseases  in.  718 

physiological  factors  in,  720 

puberty  in,  720 

puerperal  state  in,  721 

senility  in,  721 

syphilis  in,  716 

tuberculosis  in,  717 

various  poisons  in,  715 
examination  of  patient  in,  754 
general  etiology  of,  68>^ 

symptomatology  of,  726 

treatment  of,  758 
hebephrenic,  720 
heredity  in,  689 
hydrotherapy  in,  765 
hypochlorhydria  in.  752 
manic-depressive,  662.  666 
massage  in,  764 
menstruation  in,  753 
moral  causes  of,  722 
motor  disordei-s  in,  750 
of  double  form,  789 
paralyses  in,  750 
prognosis  of,  758 
progressive  systematized,  821 


908 


INDEX. 


Insanity,  prophylaxis  of,  761 

reciprocal,  722 

reflex  disorders  of,  751 

rest-cin'e  in,  764 

secretoiy  disorders  in,  751 

sensory  disorders  in,  750 

sex  in^  688 

strain  in,  713 

synonyms  of,  681 

temperature  changes  in,  753 

toxic  influences  in.  713 

trophic  disorders  in,  751 

urine  in,  752 

vascular  disorders  in,  754 
Insomnia,  632 

etiology  of,  632 

symptoms  of,  633 

treatment  of,  633 
Insular  sclerosis,  459.     See  also  Multiple 

cerebrospinal  sclerosis. 
Integument,  examination  of,  25 
Intention  tremor,  29 

in  multiple  sclerosis,  463 
Intermittent  limping,  512 
treatment  of,  513 

mania,  776 

melancholia,  785 
Intermittirende  Hinke,  512 
Internal  capsule,  function  of,  179 

lesions  of.  effect  of.  on  sensation,  56 
motor  paths  in,  179 
sensory  paths  in,  180 
Intrapial  hemorrhage,  76 
Invasion  symptoms,  186 
lodid  of  potassium  in  bronchial  asthma, 

138 
lodids  in  cerebral  hemorrhage,  215 

in  cerebrospinal  syphilis,  478 

in  intermittent  limping.  513 

in  leptomeningitis,  87 

in  neuritis,  283 
Iodoform,    injection    of.   within   dura   in 
tubercular  leptomeningitis,  94 

ointment  for  leptomeningitis,  87 
Iridoplegia.  62 
Iron  in  chorea,  540 

in  multiple  neuritis,  323 

in  neurasthenia,  573 
Irradiation,  735 
Irresein,  643 
Irritability,  737 
Irritative  brain-lesions,  186 
Irrsinn,  643 
Isolation  of  insane,  762 

Jacksoxiax  convulsions.  31 
in  cerebral  softening,  219 
fits.  545 

Jaw-jerk,  production  of,  33 

Jendrassik's  method  of  reinforcing  knee- 
jerk.  35 

Joints.  Charcot,  39,  433 

motility  of,  in  infantile  cerebral  palsies, 

244  ^ 
testing  sensibility  of,  54 
trophic  disorders  of,  39 

Judgment,  testing  of,  756 


Judgment,  weakness  of,  746 
Jumpers,  623 

Juvenile   variety  of   idiopathic   muscular 
atrojjhy,  406 

Kakideosis,  775 
Kakke,  304,  318 
Keel-shaped  skull,  695 
Knee-jerk,  34 

reinforced  by  Jendrassik's  method,  34, 
35 

Lability  of  phenomena,  738 
Labioglossolaryngeal  paralysis,  151.     See 

also  Polio-encepjhalitis  inferior  chronica. 
Labyrinthial  disturbance  in  tabes,  427 
Lachrymal  reflex  in  hysteria,  579 
Lalling,  67 

Landholt's  rule  in  testing  diplopia,  106 
Landouzy-Dejerine      type     of     muscular 

atrophy,  406 
Landry's  paralysis,  362 
course  of,  365 
diagnosis  of,  365 
etiology  of.  363 
morbid  anatomy  of,  363 
prognosis  of,  365 
symptoms  of,  364 
treatment  of,  366 
Lar^nigeal  crisis,  430 
epilepsy,  136 
muscles,  action  of,  134 
nerves,  133 
palsies  in  tabes,  430 
paralyses.  134 
abductor,  134 
adductor,  134 
complete  bilateral,  136 
diagnosis  of,  134 
of  tensors.  135 
treatment  of,  136 
spasm.  136 
stroke,  430 
Larynx,  anesthesia  of,  136 
Latah,  623 

Latent  lesions  of  cerebral  cortex,  166 
Lateropulsion,  549 
Lathyrism,  457 
Law  of  regression,  734 
Lead  in  etiology  of  insanity,  715 
Lead-cap  headache,  566 
Lead-palsy,  316 
prognosis  of,  321 
treatment  of,  322 
Leg.  center  for  movements  of.  164 
Length-breadth  index,  695,  698 
Leontiasis  ossea,  489 
Leprous  neuritis,  319 
Leptocephalus.  694 
Leptomeningitis,  77 
acute,  spinal,  270 
course  of,  272 
diagnosis  of,  272 
etiology  of,  270 
morbid  anatomy  of,  271 
Osier's  classification  of,  78 
prognosis  of,  273 


IXDEX. 


909 


Leptomeningitis,     acute,     symptoms     of, 
•.171 
treatment  of,  27;5 
chronif,  88 
spinal,  274 

morl)i(l  anatomy  of,  274 
pnjgiiosis  of,  274 
symptoms  of,  274 
treatment  of,  274 
course  of,  83 
diagnosis  of,  84 
etiology  of,  77 
headache  in,  80 
lumbar  puncture  in,  87 
pathological  anatomy  of,  79 
prognosis  of,  85 
symptoms  of,  80 
treatment  of,  86 
tubercular,  89 
course  of,  93 
diagnosis  of,  93 
etiology  of,  89 
headache  in,  91 
pathological  anatomy  of,  89 
prognosis  of,  94 
symptoms  of,  91 
treatment  of,  94 
Lesions  of  one-half  of  cord,  effect  of,  55 
of  spinal  cord,  anesthesia  in,  54 

combined,  in  anemias  and  cachex- 
ias, 448 
Leukomyelitis    posterior,    409.     See   also 

T((bes  dorsalis- 
Lids,  examination  of,  61 
Ligaments,  trophic  disorders  of,  38 
Lightning  pains  in  tabes  dorsalis,  420 
Limbs,  anomalies  of,  712 
Limp  chorea,  539 
Limping,  intermittent,  512 

treatment  of,  513 
Lingual  spasm,  146 
Lipoma  of  brain,  254 
Lipomatosis,  symmetrical,  515 
Lips,  anomalies  of,  704 
Little's  disease,  246 
Local  asphyxia,  509 
convulsions,  31 
death,  509 
syncope,  509 
Localization,  cerebral,  159 

general,  considerations  of,  159 
in  cerebral  cortex,  159 
motor  cortical,  162 
of  cord-lesion,  horizontal,  338 

vertical,  334 
of  disease-process,  653 
of  lesions  of  cauda  equina,  347 
sensory  cortical,  165 
spinal,  327 
Localized  hypertrophies,  526 

symptoms,  187 
Lockjaw,  521 
Locomotor  ataxia,  progressive,   409.     See 

also  Tabes  dormlis. 
Logorrhea,  737 
Lumbar  points,  300 

puncture  in  leptomeningitis,  87 


Lumbar  puncture  in  spinal   leptomenin- 
gitis, 27;> 
in  tubercular  meningitis,  94 
Lys-sa,  524 
Lyssophobia,  525 

Macrocephali's,  694 
IMacroglossus,  704 
Make  of  current,  42 
Maladie  des  tics,  621,  746 
Mandibular   muscles,    paralysis   of,  from 
disease  of  trifacial  nerve,  114 

reflex,  33 
Mania,  772 

acute  delirious,  775 

chronic,  776 

confused,  678 

course  of,  776 

definition  of,  772 

dementia  from,  776 

diagnosis  of,  777 

etiology  of,  772 

gravis,  775 

intermittent,  776 

mental  symptoms  of,  772 

mitis,  775 

pathology  of,  776 

periodical,  775 

physical  symptoms  of,  775 

prognosis  of,  777 

recurrent,  776 

simple,  678 

transitory,  775 

treatment  of,  777 

varieties  of,  775 
Manic  stupor,  669 
Manic-depressive  insanity,  662,  666 
^larantie  sinus  thrombosis,  227.     See  also 

Sinus  thrombosis. 
Massage  in  anterior  poliomyelitis,  381 

in  combined  sclerosis  of  cord,  447 

in  exophthalmic  goiter,  506 

in  facial  paralysis,  125 

in  infantile  cerebral  palsies,  249 

in  insanity,  764 

in  intermittent  limping,  513 

in  Landry's  paralysis,  366 

in  multiijle  neuritis,  323,  324 

in  myelitis,  358 

in  neuritis,  283 

of  brachial  plexus,  296 

in  sciatic  neuritis,  303 

in  spinal  muscular  progressive  atrophy, 
396 

in  tabes  dorsalis,  441 
Massive  type  of  acromegalia,  487 
Mastication,  center  for,  164 
Masticatory  paralysis,  113 

spasm,  113 
Mastoid  disease,  importance  of,  65 
Masturbation   in  insanity,   treatment  of, 

771 
Mathieu's  hand-dynamometer,  27 
Maximal  points  of  pain,  57 
Median  nerve,  lesions  of,  290 
Medulla  oblongata,  symptoms  of   lesions 

of,  183 


910 


INDEX. 


Megalocephalie,  489 
Megalodactyl,  710 
Megalomelus,  710 
Melancholia,  673,  675,  778 

acute  hallucinatory,  783 

affective,  676,  677 

agitata,  741,  782 

attonita,  741,  782 

catatonic,  783 

course  of,  785 

definition  of,  778 

depressive,  677 

diagnosis  of,  786 

etiology  of,  778 

hypochondriacal,  780,  783 

hypokinetic,  677 

initial,  654 

intermittent,  785 

mental  symptoms  in,  779 

passiva,  741,  782 

pathological  anatomy  of,  785 

periodical,  785 

physical  symjjtoms  of,  852 

prognosis  of,  787 

recurrent,  785 

treatment  of,  787 

varieties  of,  782 
Memory  defects,  actions  induced  by,  747 

disorders  of,  739,  740 

importance  of,  in  diagnosis,  23 

testing  of,  756 
Memory-pictures,  disorders  of,  733,  734 
Meniere's  disease,   129.      See  also  Aural 

vertigo. 
Meningeal  hemorrhage,  745 

spinal,  274 
Meninges,  cerebral,  71 

spinal,  tumors  of,  368 
Meningitis,  acute  cerebral,  77.     See  also 
Leptomeningitis  and  Pachymeningitis. 
serous,  79 

basilar,  89.     See  also  lleningitis,  tuber- 
cular. 

cerebral,  syphilitic,  469 
symptoms  of,  471 

cerebrospinal,  77.    See  also  Leptomenin- 
gitis. 

chronic  infantile,  88 

l^urulent,  77.     See  also  Leptomeningitis. 

spinal,  268 

syphilitic  spinal,  475 
Meningocele,  372 
Meningomyelitis,  spinal,  268 

syphilitic,  475 
Meningomyelocele,  372 
Menopause  in  etiology  of  insanity,  721 
Menstruation  in  insanity,  753 
Mental  condition  of  patient,  examination 
of,  22 

diseases,  643 

paralysis  and,  665,  687 

sequence  of  events  in  diagnosis,  661 

disturbance  as  a  cerebral  symptom,  188 

strain,  712 

svmptoms  in  tumor  of  brain,  256 

torticollis,  144,  623 
Meralgia,  296 


Mercurial  inunctions  in  acute  spinal  lepto- 
meningitis, 273 
in  neuritis,  283 
Mercury  in  cerebrospinal  syphilis,  478 

in  etiology  of  insanity,  715 

in  hydrocephalus,  266 

in  leptomeningitis,  87 

in  sciatic  neuritis,  303 
Merycism,  143 
Mesocephalic  head,  693 
Metallic  poisons,  insanity  and,  715 
Metatarsalgia,  298 
MicToccplialus,  694 
Micromania,  743 
Middle-ear  disease,  65 
Migraine,  615 

course  of,  617 

diagnosis  of,  618 

etiology  of,  615 

headache  in,  616 

ophthalmoi^legic,  616 

pathology  of,  618 

prognosis  of,  618 

symptoms  of,  616 

treatment  of,  619 
Mimic  spasm,  621 
Mind-blindness,  68,  171 

lesion  causing,  166 
Mirror-speech,  69 
Mirror-writing,  69 
Modal  change,  46 
Mogigraphia,  557 
Monocular  diplopia,  612 
Monomania,  649,  821 
Monoplegia,  28 

in  tumor  of  brain,  258 
Moods,  735 
Moral  causes  of  insanity,  722 

treatment  of  insane,  769 
Morbus  sacer,  602 
Morel  ear,  706,  707 
Morphin  in  caisson  disease,  368 

in  chorea,  541 

in  etiology  of  insanity,  714 

in  leptomeningitis,  86 

in  mental  disease,  767 

in  migraine,  619 

in  neuralgia,  629 

in  Raynaud's  disease.  511 

in  sciatic  neuritis,  .303 

in  tabes  dorsalis,  443 

in  tetanus,  523 
Morphological  stigmata  of  degeneracy,  21 
Morton's  disease,  298 
Morvan's  disease,  387 
Motility,  27 

increased,  29 

psychoses,  679 

reduced,  27 
Motor  aphasia,  172 

areas  of  pain,   localization  of,  by  elec- 
tricity, 48 

disorders  in  insanity,  750 

function,  anomalies  of,  711 

neuroses,  542 

points  of  face  and  neck,  40 
of  lower  extremity,  43,  44,  45 


INDEX. 


911 


Motor    points    of    upper    extremity,    41, 
42 
tracts  of  brain,  179-185 
Movement,  hallucinations  of,  728 
Movements,  associated,  31 

postplegic,  30 
Multiple  abscesses  of  brain,  236 
cerebrospinal  sclerosis,  459 
bulbar  symptoms  of,  465 
cerebral  symptoms  of,  465 
course  of,  465 
diagnosis  of,  466 
etiology  of,  459 
forms  of,  465 
intention  tremor  in,  463 
morbid  anatomy  of,  461 
motor  features  of,  462 
prognosis  of,  467 
sensory  symptoms  of,  464 
symptoms  of,  462 
treatment  of,  467 
trophic  disturbances  in,  465 
vertigo  in,  465 
visual  disturbances  in,  465 
neuritis,  304.     See  also  Neuritis. 

recurrent,  319 
neuromata,  284 

paralyses  of  cranial  nerves,  148 
Muscles,  electrical  testing  of,  40 
testing  of  power  of,  27,  28 
trophic  disorders  of,  38 
Muscular  sense,  testing  of,  51 
spasm,  idiopathic,  37 
system,  examination  of,  27 
Musculospiral  nerve,  lesions  of,  289 
Mutism  in  hysteria,  67 
Myasthenic  reaction,  47 
Myelinic  neuromata,  284 
Myelitis,  351 

acute  bulbar,  156 
syphilitic,  476 
atrophy  in,  354 
central,  352 
course  of,  356 
diagnosis  of,  356 

differential,  357 
disseminated,  352 
etiology  of,  352 
morbid  anatomy  of,  352 
motor  symptoms  of,  354 
paraplegia  in,  350 
prognosis  of,  357 
reflexes  in,  354 
sensory  symptoms  of,  354 
symptoms  of,  353 
transverse,  352 
treatment  of,  358  " 
trophic  changes  in,  355 
Myelocele,  372 
Myoclonia,  543 
diagnosis  of,  545 
etiology  of,  544 
prognosis  of,  545 

symptoms  of,  544  .; - 

treatment  of,  545 
Myoclonus,  543 
epilepsy,  610 


Myoclonus,  contractions  in,  511 

diagnosis  of,  611 

prognosis  of,  611 

treatment  of,  611 
Myoidema,  37,  310 
Myoidism  in  tabes,  419 
Myopathic  facies,  399 
Myopathy,  primitive  progressive,  397 
Myositis  in  multiple  neuritis,  304 
Myotonia,    31,  552.     See  also    Thomnen's 

disease. 
•    congenita,  552 

family,  552 
Myotonic  reaction,  47 
Myriachit,  623 
Mysophobia,  719 
Myxedema,  490 

acquired,  of  adults,  490 

congenital,  492 

etiology  of,  495 

morbid  anatomy  of,  496 

operative,  492 

treatment  of,  496 
Myxedematous  idiocy,  492 

retardation,  494 

Narcolepsy,  636 

Narrow-headedness,  694 

Nasal  crises  in  tabes,  427 

Naso-occipital  arc,  643,  698 

Nasus  aduncus,  705 

Negation,  delusion  of,  744 

Nephritic  crisis,  429 

Nephritis  in  etiology  of  insanity,  717 

Nerve,  circumflex.     See  Circumflex  nerve. 

divided,  changes  in,  277 
regeneration  of,  278 
symptoms  of,  277 
treatment  of,  279 

division  of,  277 

electric  tests  of,  in  health,  43 

median.     See  3Iedian  nerve. 

musculospiral.     See  Musculospiral  nerve. 

phrenic.     See  Phrenic  nerve. 

suprascapular.    See  Suprascapular  nerve. 

suture  of,  279 

thoracic.     See  Tlioracic  nerve. 

ulnar.     See   Ulnar  nerve. 
Nerve-grafting  for  neuromata,  286 
Nerves,  cutaneous  distribution  of,  52,  53 

electrical  testing  of,  39 

inflammation  of,  279.    See  also  Neuritis- 

of  lower  extremity,  lesions  of,  296 

of  trunk,  lesions  of,  296 

spinal.     See  Spinal  nerves. 
Nerve-stretching  for  neuromata,  286 
Nerve-trunk,  lesion  of,  anesthesia  in,  54 
Nerve-tumors,  283.     See  also  Neuromata. 
Nervous  coughs,  137 

diseases,  functional,  481. 

organic,  in  etiology  of  insanity,  718 

dyspepsia,  143 

exhaustion,  563.    See  also  Neurasthenia. 
in  etiology  of  insanity,  719 

prostration,  563.    See  also  Neurasthenia. 

system,  syphilis  of,  467 
Neuralgia,  625 


912 


INDEX. 


Neuralgia,  characters  of,  G26 
conditions  favoring,  626 
in  branches  of  trifacial,  116 
in  insanity,  750 
pathology  of,  627 
treatment  of,  628 
trifacial,  628 
varieties  of,  627 
Neurasthenia,  563 

circulatory  disorders  in,  567 
course  of,  570 
diagnosis  of,  570 
disorders  of  hearing  in,  567 

of  smell  in,  567 

of  taste  in,  567 
etiologj'  of,  563 
fear  in,  569 
forms  of,  570 

gastro-intestinal  disorders  in,  567 
general  state  in,  569 
genital  disorders  in,  568 
headache  in,  566 
mental  disturbances  in,  568 
motor  disorders  of.  565 
nosophobias  in,  569 
photophobia  in,  567 
prognosis  of,  571 
secretory  disorders  in,  568 
sensory  disturbances  in,  565 
sleep  in,  569 
symptoms  of,  565 
tenderness  in,  566 
traumatic,  620 
visual  disturbances  in,  566 

field  in,  63 
Ketiritis,  279 

adventitiotis,  280 
alcoholic,  316 
diagnosis  of,  282 
etiology  of,  279 
leprous,  319 
migrans,  280 
morbid  anatomy  of,  279 
multiple,  304 

accommodation  in,  313 

alcoholic  form  of,  316 

course  of,  315 

diagnosis  of.  320 

of  the  toxic  cause  of,  321 

differential   diagnosis   of,    from    hys- 
teria, 321 
from  lead  poisoning,  316 
from  locomotor  ataxia,  320 
from  myelitis,  320 
from  pernicious  anemias,  321 
from  poliomyelitis,  320 

electrical  changes  in,  309 

etiology  of,  304 

general  conditions  in,  313 

lesions  in  muscles  in,  306 
in  nerves  in,  305 
of  brain  in,  306 
of  spinal  cord  in,  306 

morbid  anatomy  of,  305 

motions  of  eyes  in,  313 

nutrition  in,  313 

prognosis  of,  321 


Neuritis,  multiple,  pupils  in,  313 
recurrent,  319 
reflexes  in,  311 
special  forms  of,  315 
symptoms  of,  307 
mental,  313 
motor,  307 
muscular,  307 
ocular,  312 
sensory,  311 
treatment  of,  322 
trophic  conditions  in,  313 
vision  in,  312 
of  brachial  plexus,  294 
causes  of,  294 
diagnosis  of,  295 
prognosis  of,  295 
symptoms  of,  294 
treatment  of,  296 
of  branches  of  trifacial,  116 
optic,  101 

as  a  symptom,  189 
parenchymatous,  279 
prognosis  of,  282 
sciatic,  298 
causes  of,  299 
diagnosis  of,  301 
double,  301 

morbid  anatomy  of,  299 
symptoms  of,  299 
tender  points  in,  300 
treatment  of,  302 
symptoms  of,  280 
syphilitic,  477 
treatment  of,  282 
Neuroma  of  brain,  254 
Neuromata,  283 
amputation,  284 
amyelinic,  284 
cellular,  284 
diagnosis  of,  285 
dolorosa,  284 
etiology  of.  285 
fibrillar,  284 
ganglion,  284 
multiple,  284 
myelinic,  284 
prognosis  of,  285 
symptoms  of,  285 
traumatic,  284 
treatment  of,  285 
Neuroretinitis,  101 
Neuroses,  481 

classification  of,  481 
fatigue,  556 

following  traumatism,  619 
infection,  521 
motor,  542 

occupation,  20,  556,  562 
Neurotabes,  439 

Neurotic  heredity  in  diagnosis,  18 
Nightmare.  635 
Night-terrors,  23,  635 
Ninth  nerve.     See  Glossophnrynfjeal  nerve. 
Nitrite  of  amyl  in  bronchial  asthma,  139 

in  tetanus,  523 
Nitroglycerin  in  migraine,  619 


INDEX. 


9ia 


Nitroglycerin  in  sciatic  neuritis,  303 
Nocturnal  enuresis,  63G 

epilepsy,  <)(»s 
Noddinti  spasm  in  hysteria,  503 
Normal  child,  development  of  the  faculties 

of,  H73 
Nose,  anomalies  of,  705 
Nosebleed  after  middle  life,  197 
Nutrition,  abnormal  \ariations  in,  37 
Nystagmus,  110 

Oblique  line,  168     . 
Obturator  nerve,  lesions  of,  297 
Occupation  neuroses,  20,  556,  562 

predisposing  to  nervous  disease,  20 
Ocular  muscle,  spasms  of,  110 

muscles,  action  of,  104 

nerves,  anatomical  considerations  of ,  103 
diseases  of,  103 

palsies,  105 
causes  of,  109 
diagnosis  of,  106 
location  of  lesion  in,  108 
treatment  of.  111 
Oculomotor  apparatus,  double  cortical  rep- 
resentation of.  104 
Olfactorv  nerve,  diseases  of,  95 
Oligodactyly,  710 
Oligomelus,  710 
Oliguria  in  insanity,  752 
Operative  myxedema,  492 
Ophthalmoplegia  externa,  62 

interna,  62 

progressive,  149.     See  also  Polio-enceph- 
alitis superior  chronica. 
Ophthalmoplegic  migraine,  616 
Ophthalmoscope,  importance  of,  to  neurol- 
ogist, 62 
Ophthalmoscopic     picture     in    amaurotic 

family  idiocy,  247 
Opisthognathism,  696 
Opisthotonos  in  cerebellar  disease,  184 
Opium  in  epilepsy,  615 

in  insanity.  767 

in  mania,  778 

in  melancholia,  788 

in  paralytic  dementia,  820 

in  Parkinson's  disease,  552 

in  torticollis,  144 
Opiuni-bromid  treatment  in  epilepsy,  800 
Optic  nerve,  anatomy  of,  96 
atrophy  of,  38,  i02 
diseases  of,  96 
lesions  of,  96-101 

neuritis  as  a  symptom.  189 
in  tumors  of  brain,  257 

thalami,  function  of.  181 
lesions  of,  100,  182 

tract,  lesions  of,  97-101 
Orbits,  asymmetery  of,  699 
Orthognathism,  696 

Osier's  classifieation  of  acute  leptomenin- 
gitis, 78 
Osteo-arthropathie  hypertrophiante  pneu- 

mique,  488 
Osteo-arthropathy,  hj'pertrophic,  488 
Osteoma  of  brain,  254 

5S 


Othematoma,  751 
O.xahiria  in  insanity,  752 
Oxycephalus,  694 

Pachydermatous  cachexia,  490 
Pachymeningitis,  7:5 

cervicalis  hypertrophica,  2G9 

externa,  73 
spinalis,  268 

ha!morrhagica,  73 

interna,  73 
course  of,  73 
diagnosis  of,  75 
etiology  of,  73 
pathological  anatomy  of,  73 
spinalis,  269 
symptoms  of,  74 
treatment  of,  75 
Pain,  areas  of,  visceral  disease  and,  57 

as  a  cerebral  symptom,  189 

as  a  symptom,  56 

description  of,  by  patients,  62 

in  angina  pectoris.  141 

in  Ijrain-disease,  61 

in  myelitis,  353 

in  neuritis,  280 

in  sciatic  neuritis,  299 

in  spinal  tumors,  369 

in  syphilitic  meningitis,  475 

in  tabes  dorsal  is,  420,  421 

maximal  points  of,  57 
Pain  sense,  testing  of,  51 
Palate,  asymmetrical,  700,  703 

cleft,  701 

deformities  of,  699 

dome-shaped,  700,  702 

flat-roofed,  700.  702 

gothic,  700,  702 

hip-roofed,  700,  703 

with  horseshoe  arch,  700,  702 
Palpebral  reflex,  32 
Palpitation,  cardiac,  140 

in  brain  tumor.  190 
Palsies,  combined,  of  nerves  of  arm,  293 

in  tabes  dorsalis,  419 

sleep,  637 
Palsy,  Bell's,  119 

divers',  366.     See  also  Caisson  disease. 

scriveners',  557 

wasting,  389 
Panophthalmitis  in  leptomeningitis,  81 
Papilla,  optic,  diseases  of,  101 
Papillitis.  101 

in  titmor  of  brain,  257 
Papilloneuritis,  101 
Paradoxical  contraction,  36 
Parageusia,  66 
Paragraphia,  68 
Paraldehyd  in  mania,  778 

in  mental  disease,  768 

in  senile  dementia,  806 
Paralysis,  acute  ascending,  362.     See  also- 
Landry'' s  paralysis. 

agitans,  546.     See  also  Parkinson'' s  dis- 
ease. 

Brown-Seqnard.  cord-lesion  in,  55,  56 

bulbar,  asthenic,  157 


914 


INDEX. 


Paralysis,  cerebral,  of  children,  240 
chronic  nuclear  ocular,   149.      See  also 

Polio-encepJialilis  superior  chronica. 
diphtheric,  317 

facial,  119.     See  also /acm/ jxicfl/v/.s/.s. 
family  periodic,  554 
from  brain-abscess,  2:57 
from  cerebral  hemorrhage,  220 
from  cord-lesion.  334 
hypoglossal,  147 
in  anterior  poliomyelitis,  377 
in  cerebral  softening,  219,  220 
in  hysteria,  591 
in  insanity,  750 
in  multiple  neuritis,  307 
in  myelitis,  354 
in  syphilitic  meningitis,  475 
in  tabes  dorsal  is,  419 
labioglossolaryngeal,    151.       See     also 

Polio-encephalitis  chronica. 
Landry's,  3<52 
laryngeal,    134        See    also    Laryngeal 

paralysis. 
masticatory,  113 
mental  disease  and,  G65,  687 
multiple,  of  cranial  nerves,  148 
ocular,  105.     See  also  Ocular  palsy. 
of  anterior  crural  nerve,  29G 
of  auditory  nerve,  128 
of  circumflex  nerve,  288 
of  facial  nerve,  119 
of  median  nerve,  290 
of  musculospiral  nerve,  288 
of  obturator  nerve,  297 
of  i^hrenic  nerve,  28G 
of  posterior  thoracic  nerve,  287 
of  sciatic  nerve,  297 
of  spinal  accessory  nerve,  145 
of  superior  gluteal  nerve,  297 
of  suprascapular  nerve,  287 
of  tongue,  147 
pharyngeal,  133 
progre.ssive  bulbar,  151.    See  also  Po^/o- 

encephaliiis  inferior  chronica. 
pseudobulbar,  15G 
p.seudohypertrophic,  405 
syphilitic  spinal,  7G 
iilnar,  292 
Paralytic  chorea,  539 
dementia.  802,  808 

definition  of,  808 

diagnosis  of,  817 

differentiation    of,    from    alcoholism, 
817 
from  cerebrospinal  syphilis,  818 
from  multiple  sclerosis,  819 
from  neurasthenia,  817 

duration  and  prognosis  of,  816 

etiology  of,  808 

mental  symptoms  of,  811 

pathological  anatomy  of,  819 

physical  symptoms  of.  Hll 

prodromal  period  of.  wlO 

symptomatology  of,  810 

terminal  period  of,  816 

treatment  of,  820 
Paramimia.  68,  171 


Paramyoclonus,  543 

multiplex,  544 
Paramyotonia,  congenital,  553 
Paranoia,  649,  821 
circular,  675 

course  and  prognosis  of,  844 
definition  of,  821 
erotica,  825 
etiology  of,  822 
expansive  period  of,  825 
from  mania,  776 
hallucinatoria  acuta,  675,  821 

chronica,  675,  821 
inventoria,  825 
morbid  anatom^^  of,  844 
persecutory  period  of,  823 
prodromal  period  of,  822 
querulans,  825 
reformatoria,  825 
religiosa,  825 

secondaria  melancholia,  786 
simplex  acuta,  675,  821 

chronica,  821 
symptomatology  of,  822 
treatment  of,  844 
varieties  of,  821 
Paraphasia,  171,  173 
Paraphrasia,  68 
Paraplegia,  28,  359.     See  also  Paraplegic 

state. 
ataxic,  444 

siS'philitic,  476 
from  hematomyelia,  350 
hereditary  spastic,  456.     See  also  Hered- 
itary spastic  paraplegia. 
in  myelitis,  359 
in  spinal  tumors,  370 
Paraplegic  gait,  360 
state,  attitude  in,  361 

etiology  of,  359 

gait  in,  360 

in  myelitis,  359 
prognosis  of,  362 

reflexes  in,  361 

symptoms  of,  359 

treatment  of,  362 
Parasyphilitic  diseases,  479 

acquired,  479 

hereditary,  480 
nervous  disease,  467 
Parenchymatous  neuritis,  279 
Paresis,  general,  in  cerebral  hemorrhage, 

213 
Paresthesia  in  multiple  neuritis,  311 

in  neuritis,  280 
Paresthesise,  54 
Parkinson's  disease,  546 

C(mrse  of,  551 

diagnosis  of,  551 

etiology  of,  546 

mental  state  in,  551 

morbid  anatomy  of,  546 

muscular  rigidity  in,  547 

palsy  in,  550 

sensory  disturbances  in,  55Q 

symptoms  of,  547 

treatment  of,  551 


INDEX. 


915 


Parkinson's  disease,  trembling  in,  549 
Past  illness,  investigation  of,  19 
Patellar  point,  3U0 

retli'x,  1)4 
Patient,  antecedents  of,  18 

examination  of,  17-70 
Pavor  nocturnus,  63") 
Pellagra,  458 

Percussion  in  brain  disease,  189 
Peri-arteritis,  cerebral,  196 
Perineuritis,  28L> 
Periodical  mania,  775 

nu'lancholia,  785 

swelling,  51:3 
Peripheral  nerves,  trophic  disease  of,  38 

paralysis  in  insanity,  750 
Peroneal  nerve,  lesions  of,  '297 

variety  of  idiopathic  muscular  atrophy, 
406 
Persecution,  delusion  of,  743 
Personal  history,  19 
Peterson's  calipers,  698,  697 
Petit  mal,  608 
Pharyngeal  crises,  430 

paralysis,  133 

reflex-,  33 

spasm,  133 
Phenacetin  in  acromegalia,  488 

in  epilepsy,  614 

in  tabes  dorsalis,  443 
Phoconielus,  710 
Phosphaturia  in  insanity,  752 
Photophobia  as  a  symptom,  61 

in  leptomeningitis,  81 
Phrenic  nerve,  lesions  of,  288 
Physical  examination,  23 

strain,  712 
Physiognomy  of  patient,  21 
Physiological  factors  in  etiology  of  insan- 
ity, "20 
Pia  mater,  748 

inflammation  of,  77.      See  also  Lepto- 
meniiu/itis. 

visceral,  71 
Pial  hemorrhage,  75 

space,  71 
Pilocarpin  in  aural  vertigo,  132 

in  nervous  deafness,  129 
Pituitary  tumor  with  acromegaly,  254 
Plagiocephalus,  694 
Plantar  nerve,  external,  lesions  of,  298 
internal,  lesions  of,  298 

points,  300 

reflex,  36 
Platicephalus,  694 

Pneumococcus  in  leptomeningitis,  78 
Pneumogastric  nerve.     §ee  Vagus. 
Polar  change,  16 
Polio-eucephalibis,  combined  forms  of,  156 

inferior  chronica,  151 
course  of,  155 
diagnosis  of,  155 
etiology  of,  152 
morbid  anatomy  of,  152 
symptoms  of,  152 
treatment  of,  156 

superior,  acute,  151 


Polio-encephalitis  superior  chronica,  149 
course  of,  150 
diagnosis  of,  151 
etiology  of,  149 
pathological  anatomy  of,  149 
symptoms  of,  149 
treatment  of,  151 
Poliomyelitis,  acute  anterior,  374 
course  of,  379 
deformity  in,  378 
diagnosis  of,  379 
etiology  of,  374 
forms  of,  379 
morbid  anatomy  of,  374 
prognosis  of,  380 
symptoms  of,  377 
treatment  of,  380 
chronic,  389 
Polydactyly,  710 
Polymastia,  710 

Polyneuritis,  304.     See  also  Neuritis,  mul- 
tiple. 
Polyuria  in  insanity,  752 
Pons  Varolii,  function  of,  182 

symptoms  of  lesions  of,  182 
Popliteal  nerve,  external,  lesions  of,  297 
internal,  lesions  of,  298 
point,  300 
Posterior  columns  of  cord,  effect  of  lesions 
of,  338 
horn  of  cord,  effect  of  lesions  of,  346 
roots  of  cord,  effect  of  lesions  of,  346 
spinal  arteries,  333 
Posterolateral    sclerosis,     444.     See    also 

Combined  sclerosis  of  cord. 
Postplegic  movements,  30 
Precordial  anxiety,  736 

fright,  736 
Present  condition  of  patient,  23 
Pressure  sense,  testing  of,  51 
Primare  Verriicktheit,  649 
Primary  dementia,  649,  802,  806 
Prodromes,  epileptic,  605 
Prognathism,  696 

Progressive    bulbar   paralysis,    151.     See 

also  Polio-encephalitis  inferior  chronica. 

general  paralysis,  808.     See  also  Parahj- 

tic  dementia.. 
locomotor  ataxia,  409.     See  also  Tahes 

dorsalis. 
muscular  atrophy,  388 
idiopathic,  397 
course  of,  405 
etiology  of,  398 
morbid  anatomy  of,  398 
prognosis  of,  406 
symptoms  of,  399 
treatment  of,  406 
varieties  of,  405 
spinal,  388 
course  of,  395 
diagnosis  of,  395 
differential  diagnosis  of,  396 
etiology  of,  389 
morbid  anatomy  of,  390 
prognosis  of,  397 
symptoms  of,  391 


9i6 


INDEX. 


Progressive  bulbar  paralysis,  spinal,  treat- 
ment of,  396' 
varieties  of,  395 
with  cord  lesions.     See  Progics^ice 

muscular  atrophy,  spinal. 
without  cord  lesions.     See  Prog  res- 
sice  muscular  atrophy,  idiopathic. 
dystrophy,  397 
ophthalmoplegia,  149.     See  also  Polio- 
encephalitis superior  chronica. 
spastic  ataxia,  444.     See  also  Combined 

sclerosis  of  spinal  cord. 
systematized    insanity,    821.     Bee   also 
P<iranoia. 
Projectile  vomiting  as  a  symptom,  188 
Propulsion,  549 
Psammoma,  254 
Pseudo-apraxia,  742 
Pseudo-ataxia,  742 
Pseudoataxie  cerebelleuse,  450 
Pseudobulbar  paralyses,  156 
Pseudochorea,  742 
Pseudodementia,  738 
Pseudohypertrophic  paralysis,  405 
Pseudomeningitis,  hysterical,  594 
Pseudoparaphrasia,  741 
Pseudoi>aresLs,  syphilitic,  473 
Pseudotabes,  439 
Psychiatry,    review    of   recent   problems, 

650 
Psychic  degeneration  of  epileptics,  795 

equivalent  of  epileptic  attack,  609 
Psychopathy,  643 
Psychosis,  643 
anxietj^,  676 
classification,  652 
derangement  and,  657 
hyperkinetic  motilit3\  678 
motility.  679 
Psychotherapy,  769 
Ptosis  as  a  symptom,  61 
Ptosis,  sleep,  636 

Puberty  in  etiology  of  insanity,  684,  720 
Puerperal    state  in  etiolog}'   of   insanity, 
721 
tetanus,  522 
Pulmonarv  branches  of  vagus,   affections 

of.  137 
Pulse  in  leptomeningitis,  82 

in  polio-encephalitis  inferior  chronica, 

154 
in  spinal  leptomeningitis,  274 
in  tubercular  leptomeningitis,  92 
Pupil,  irregularities  of,  62 
Pupillary  reflex,  32 
Pupils  in  leptomeningitis,  82 

in  7iiultiple  neuritis,  313 
Purulent  meningitis,  77.     See  also  Lepto- 

mminr/itis. 
Pyramidal  tracts,  effect  of  lesions  of,  338 

Qualitative  change,  46 
Quantitative  change,  46 
Quincke's  disease,  513 

lumbar  puncture  in  spinal  leptomenin- 
gitis, 211 
Quinin  in  aural  vertigo,  132 


Quinin  in  chorea,  541 
in  multiple  neuritis,  323 

sclerosis,  467 
in  neuralgia,  629 

Rabies,  523 

liaptus  melancholicus,  782,  783 

Eaynaud's  disease,  509 

course  and  prognosis  of,  510 
diagnosis  of,  510 
etiology  of,  509 
symptoms  of,  510 
treatment  of,  511 
Eeaction,  hemianopic  pupillary,  99 

myasthenic,  47 
,    myotonic,  47 

of  degeneration,  45 
in  facial  paralysis,  122 
partial,   47 
Reciijrocal  insanity,  722 
Rectus  clonus,  36 

reflex,    35 
Recurrent  mania,  776 

melancholia,  785 

multiple  neuritis,  319 
Red  cerebral  softening.  217 
Referred  sensation,  54 
Reflected  tone,  735 
Reflex,  abdominal,  34 

Achilles  tendon,  36 

anal,  36 

sphincteric,  36 

bulbocavernous,  429 

ciliary,  32 

cremasteric,  36 

disorders  in  insanity,  751 

epigastric,  34 

heel-tendon,  36 

mandibular,  33 

palpebral,  32 

patellar,  34 

pharyngeal,  33 

plantar,  36 

pupillary,  32 

rectus,  35 

sphincter,  36 

triceps,  34 

virile,  429 
Reflexes,  31 

in  anterior  poliomyelitis,  377 

in  hysteria,  580,  581,  591 

in  lesions  of  spinal  cord,  336 

in  multiple  neuritis,  311 

in  myelitis,  354 

in  myoclonus  epilepsy.  511 

in  paraplegic  state,  361 

in   progressive  muscular  atrophy   with 
cord  lesions,  394 

in  spinal  tumors,  370 

in  tabes  dorsalis,  423 

of  lower  extremity,  34 

of  upper  extremity,  33 
Refraction,  errors  of,  importance  of,  62 
Refusal  of  food,  management  of,  771 
Regeneration  of  a  divided  nerve,  278 
Regression,  law  of,  734 
Residence,  importance  of,  20 


INDEX. 


917 


Respiration  in  leptonieniiij^itis,  83 

in  tubercular  leptouienin<iitis,  91 
Respiratory  organs,  examination  of,  24 
Rest  in  multiple  neuritis,  323 

in  neuritis,  2^2 

in  sciatic  neuritis,  302 
Rest-cure,  7(i4 
Retina,  diseases  of,  101 
Retinitis,  101 
Retropulsion,  519 
Reversion,  (JUO 

Rheumatism,  relation  of,  to  chorea,  531 
Rifrlit-handedness.  cause  of,  1(J2 
Rigidity  in  tubercular  leptomeningitis,  91 

muscular,  in  leptomeningitis,  71 
Rinne's  test,  64 

Robertson  pupillary  sign  in  tabes,  425 
Romberg,  sign  of,  417 

symptoms,  29 
Rumination,  143 

Sagittal  line,  167 

Salicylate   of   soda   in   auto-intoxication, 

767 
Salicylates  in  anterior  poliomj'elitis,  381 

in  facial  paralysis,  125 

in  Landry's  paralysis,  366 
Salol  in  auto-intoxication,  767 

in  epilepsy,  614,  801 

in  multiple  neuritis,  323 

in  myelitis,  358 
Saltatory  chorea  in  hysteria,  593 
Sarcoma  of  brain,  251 
Scanning  speech,  6  7 
Scaphocephalus,  695 
Sciatic  nerve,  great,  lesion  of,  297 

neuritis,  298.     See  also  Neuritis. 

scoliosis,  300 
Sclerodactylie,  507 
Scleroderma,  507 

etiology  of,  50S 

symptoms  of,  508 

treatment  of,  509 
Scleroma  adultorum,  507 
Sclerose  en  plaques,  459 
Scleroses  of  spinal  cord,  combined,  444 
Sclerosis,  amyotrophic  lateral,  389 

disseminated,  459 

multiple   cerebrospinal,   459.     See  also 
Multiple  cerebrospinal  sclerosis. 

of  posterior  columns  of  cord,  409.     See 
also  Tabes  dorsal  is. 

of   spinal   cord   from  vegetable  intoxi- 
cants, 457 

posterolateral,  444.       See  also  Combined 
sclerosis. 

sciatic,  300 
Scotch  douche,  766 
Scotoma,  central,  99 
Scotomata,  63 
Scriveners'  palsy,  557 
Secondary  dementia,  649,  802,  800.     See 

also  Dementia. 
Secretory  disorders  in  insanity,  751 
Sedati\f>s  in  leptomeningitis,  86 
Sejunction,  657 
Senile  chorea,  544 


Senile  dementia,  802,  804.     See  also  De- 
mentia. 
Senility  in  etiology  of  insanity,  718 
Sensation,  disorders  of,  in  insanity,  727 
intensity  of,  732 
qualitative,  727 
tone  of,  732 
general  consideration  of,  49 
referred,  54 

testing  and  examination  of,  49 
Sensibility,  hallucinations  of,  728 

illusions  of,  732 
Sensory  conditions,  49 

disorders,  actions  indorsed  by,  747 

in  insanity,  750 
disturbances  from  brain-lesion,  187 
function,  anomalies  of,  711 
paths,  180 

tone,  disorders  of,  732 
Seventh  cranial  nerve.     See  Facial  nerve. 
Sex  in  etiology  of  insanity,  688 
Shaking  palsy,  546 
Shingles,  324.     See  also  Herpes  zoster. 
Shoulder,  center  for  movements  of,  164 
Sight,  affections  of,   in  tubercular  lepto- 
meningitis, 92 
examination  of.  61 
hallucinations  of,  728 
Signal  sj'mptom,  31,  187 
Simulo  in  epilepsy,  800 
Sinus  thrombosis,  226 
infective,  228 
cavernous,  229 
lateral,  230 
longitudinal,  231 
symptoms  of,  229 
treatment  of,  231 
marantic,  227 
diagnosis  of,  227 
prognosis  of,  228 
s^'mptoms  of,  227 
Siiiuses,  cerebral,  anatomy  of,  225 
Sixth  nerve,  anatomical  considerations  of, 
104 
effect  of  division  of,  105 
Skin,  anomalies  of.  711 

trophic  disturbances  of,  38 
Sleep,  conditions  favoring,  670 
disorders  of,  630 
drunkenness,  635 
importance  of.  in  diagnosis,  23 
palsy,  289,  637 
physical  features  of,  631 
ptosis,  638 

requirements  for,  632 
Sleeping  sickness.  637 
Smell,  center  for.  166 
examination  of.  65 
hallucinations  of,  728 
illusions  of,  732 
loss  of,  95 
Sodium   iodid   in   cerebrospinal  syphilis, 

478 
Softening,  cerebral,  216.    See  also  Cerebral 

softening. 
Somatic  consciousness,  658 
Somnambulism,  634 


918 


INDEX. 


Somnolentia,  635 
Sounds,  subjective,  64 
Space  sense,  disturbance  of,  65 
Spasmodic  asthma,  137.    See  also  Asthma, 
broncJiial. 
tabes,  444 
torticollis,  143,  623 
wr^^neck,  143 
Spasmogenic  point  or  zone,  582 
Spasms,  30 
clonic,  30 
facial,  119,  623 
from  cord-lesions,  334 
hypoglossal.  146 
hysterical  rhytlimical,  593 
idiopatliic  muscular,  37 
laryngeal,  136 
lingual,  146 
masticatory,  113 
mimic,  621 
occupation,  556 
of  ocular  muscle,  110 
of  spinal  accessory  nerve,  143 
pharyngeal,  133 
tonic,  30 
Spastic  paraplegia,   hereditary,   456.     See 

also  Hereditary  spastic  jiaraplegia. 
Spatial  analysis.  659,  660 
Special  senses,  examination  of,  601 
Speech,  anomalies  of,  712 
center  for,  165,  16rt 
examination  of,  60 
Sphincter  reflex,  36 
Spina  bifida.  372 

diagnosis  of,  373 
etiology  of,  372 
occulta,  372 
prognosis  of,  367 
symptoms  of,  372 
treatment  of,  373 
Spinal   accessory  nerve,   anatomical   con- 
siderations of.  143 
paralysis  of.  145 
spasm  of,  1-!.') 
arteries,  anterior.  329 

posterior,  333 
cord,  anatomical  considerations  of,  327 
circulation  in,  329 
combined  sclerosis  of,  444.     See  also 

Co rnh  i ned  scleros is . 
disabling  transverse  lesions  of,  table 

of  symptoms,  339-345 
glioma  of,  368 
hemorrhage  into,  348 
in  brain  tumors,  255 
indiscriminate  lesions  of,  348 
lesions  of,  combined,  in  anemias  and 
cachexias,  448 
cross,  table  of  symptoms  in,  339-345 
in  tabes  dorsal  is,  414 
localization  of,  vertical,  334 
location  of  anesthesia  in,  54 
motor  symptoms  of.  334 
of  gray  matter  of,  374 
of  one  lateral  half  of,  55 
reflexes  in,  336 
.sensory  symptoms  of,  336 


Spinal  cord,  lesions  of,  trophic  conditions 
in,  337 
vasomotor  disturbance  in,  337 
vertical  localization  of,  334 
visceral  symptoms  in,  337 
wliite  matter  of,  409 
localization  of,  327 
relation  of  lesions  and  diseases  of,  346 
to  body  surface,  328 
to  vertebrse,  328 
segments,  relation  of  anesthesia  to,  54 

to  cutaneous  areas,  55,  58 
symptoms,  functions  of,  335 
syphilis   of,   475.     See   also  Syjjhilis, 

spinal. 
thrombotic  softening  of,  351 
transverse  sections  of,  330 
traumatic  lesions  of  substance  of,  348 
tumors  of,  368 
douche,  765 
leptomeningitis,  acute,  270 

chronic,  274 
meningeal  hemorrhage,  274 
meninges,  tumors  of,  368 
meningitis,  268 
nerves,  division  of,  277 

histological  changes  in.  277 
muscular  symptoms  of,  278 
sjnnptoms  of,  277 
treatment  of.  279 
injuries  and  diseases  of,  276 
lesions  of.  in  tabes  dorsalis,  413 
special  lesions  of,  286 
pachymeningitis,  268 
stretching  in  family  ataxia,  456 

in  tabes  dorsalis,  441 
symptoms  in  tubercular  leptomeningi- 
tis, 93 
syphilis,  475.      See  also  Syphilis,  spinal. 
tumors,  368 
course  of,  370 
diagnosis  of,  371 
location  of,  371 
morbid  anatomy  of,  369 
prognosis  of.  370 
reflexes  in,  370 
symptoms  of,  369 
treatment  of,  371 
Spine,  concussion  of,  619 
Sporadic  cretinism,  492 
Spurious  ankle-clonus,  37 
Squamosal  point,  168 
Squint,  importance  of,  62 
St.  Vitus'  dance,  530 
Stahl  ear,  No.  1,  706.  707 

No.  2,  707 
Stammering,  67 
Staphylococcus  aureus  in  chorea,  534 

pyogenes  in  chorea,  534 
Static  ataxia,  29 
Status  epilepticus,  608 
Steeple-shaped  skull,  694 
Stereoagnosis,  50 
Stereognostic  sense,  50 

impairment  of,  in  tabes  dorsalis,  422 
Stereotyped  movements,  741,  748 
Sthenic  loss  in  cerebellar  disease,  184 


INDEX. 


919 


stigmata  hereditatis,  G90 

of  degeneracy  in  nervous  disease,  21 
of  degeneration  in  insanity,  (590 
Stimulants  in  leptomeningitis,  8(i 
"Stoppage,"  308 
Storm  center,  186 
Strain,   pliysical  and  mental,    in  etiology 

of  insanity,  71 '2 
Stream    of    thought,  actions    induced   by 

disorders  of,  74S 
•Strei)toc()Ccns  in  chorea,  534 
in  leptomeningitis.  7H 
"Stroke,"  ap()])li'ctic,  204 
Strophantluis  in  exophthalmic  goiter,  506 
Struma  exophthalmica,  497 
Strychnin  in  anterior  jjoliomyelitis,  381 
in  brain-tumor,  263 
in  bronchial  asthma,  138 
in  cerebral  hemorrhage,  214 

softening,  224 
in  chorea,  541 

in  exophthalmic  goiter,  506 
in  nervous  deafness,  129 
in  neuralgia,  630 
in  neurasthenia,  573 
in  neuritis,  283 

in  polio-encephalitis  superior  chronica, 
151 
Stupiditas,  806 
Stupor,  741 

manic,  669 
Stuttering,  67 
Subdural  space,  71 
Subjective  sounds,  hearing  of,  64 
Suicidal  tendencies,  management  of,  770 
Sulphonal  in  chorea,  540 
in  insanity,  768 
in  mania,  778 
Suprascapular  nerve,  lesions  of,  287 
Syllable  stumbling,  67 
Symelus,  710 

Symmetrical  lipomatosis,  515 
Sympathetic  nerve,  effect  of    division  of, 

'106 
Symptom,  extension,  186 
'    group  of  Weber,  108 
invasion,  186 
Romberg,  29 
signal,  31,  187 
Symptomatic  disorders,  625 
Symptoms  at  a  distance,  190 
"diffused,  187 
localized,  187 
Syndactyly,  710 
Syndrome,  Weber's,  182 
Synergy,  28 

.Syphilis,  cerebral,  469  - 
arterial  form  of,  472 
diagnosis  of,  473 
general  symptoms  of,  470 
gummatous  form  of,  473 
headache  in,  471 
meningeal  form  of,  472 
mental  symptoms  of,  473 
prognosis  of,  474 
special  symptoms  of,  471 
treatment  of,  475,  478 


Syphilis,  hereditary  cerebros])inal,  477 

in  etiology  of  insanity,  716 

inherited,  predisposing  to  nervous  dis- 
ease, 18 

of  cranial  nerves,  470 

of  nervous  system,  467 
acquired,  4()8 

spinal,  diagnosis  of,  477 
prognosis  of,  477 
treatment  of,  478 
Syphilitic  ataxic  jjaraplegia,  476 

cereljral  arteritis,  469 
menuigitis,  469 

cerebritis,  469 

meningomyelitis,  475 

mental  di.sease,  473 

myelitis,  476 

neuritis,  477 

pseudoparesis,  473 

softening  of  cord,  476 

spinal  meningitis,  475 
paralysis,  476 

tumors  of  brain,  253 
Syphilophobia,  473 
Syringomyelic  dissociation,  385 
Syringomyelitis,  382 

anesthesia  in,  385 

arthropathies  in,  386 

atrophy  in,  386 

clinical  forms  of,  387 

course  of,  387 

diagnosis  of,  388 

etiology  of,  382 

morbid  anatomy  of,  383 

Morvan's  type  of,  387 

motor  disturbances  in,  386 

prognosis  of,  388 

sensory  disturbances  in,  385 

symptoms  of,  384 

treatment  of,  388 

trophic  features  of,  386 

unusual  symptoms  of,  387 

vasomotor  symptoms  of,  387 


Tabes,  combined,  444 
dorsal  is,  410 

amyotrophia  in,  436 

analgesia  in,  421 

ataxia  in,  417 

auditory  symptoms  in,  426 

bones  in,  431 

cerebral  disturbances  in,  436 

constipation  in,  428 

course  of.  437 

cramps  in,  420 

crises  in,  427 

diagnosis  of,  439 

diarrhea  in,  428 

differential  diagnosis  of,  439 

disorders  of   generative   function  in, 
429 
of  intestines  in,  428 
of  nutrition  in,  431 
of  osseous  system  in,  431 
of  respiratory  apparatus  in,  430 
of  skin  in,  435 


920 


index: 


Tabes  dorsalis,  disorders  of   stomach  in, 
427 
of  urinary  apparatus  in,  428 
,,of  vascular  apparatus  in,  430 

disturbance  of  the  reflexes  in,  423 

etiology  of,  411 

gastric  crises  in,  427 

girdle  sensation  in,  421 

glycosuria  in,  429 

herpes  zoster  in,  435 

hypei-algesia  in,  422 

impairment  of  stereognostic  sense  in, 
422 

impotence  in,  429 

involuntary  movements  in,  419 

labyrinthine  disturbance  in,  427 

laryngeal  crises  in,  430 
stroke  in,  430 

lightning  pains  in,  420 

morbid  anatomy  of,  412 

motor  disturbances  in,  417 

muscles  in,  lack  of  tonicity  of,  423 

muscular  atrophies  in,  436 

myoidism  in,  419 

nasal  crises  in,  427 

nephritic  crises  in,  429 

optic  nerve  in,  42G 

pains  in,  420 

palsies  in,  419 

perforating  ulcer  in,  435 

pharyngeal  crises  in,  430 

phenacetin  in,  443 

prognosis  of,  440 

ptosis  in,  425 

pupils  in,  425 

rarefying  osteitis  in,  432 

Eobertson's  sign  in,  425 

Eomberg's  sign  in,  417 

sensory  disturbances  in ,  420 

spontaneous  fractures  in,  431 

squint  in,  425 

symptoms  of,  416 
tabulation  of,  437 

tabetic  arthropathy  in,  432 

temperature  in,  431 

treatment  of,  440 

trophic  cutaneous  disorders  in,  435 
disorders  in,  431 

urotropin  in,  443 

valvular  disease  in,  430 

varieties  of,  438 

visceral  disorders  in,  427 

visual  disturbances  in,  425 

vomiting  in,  427 

Westphal's  sign  in,  423 
spasmodic,  444 
Tabetic  arthropathy,  432 
crises,  427 
cuirass,  422 
fractures,  431 
joint,  433 
Tache  cerebrale  in  leptomeningitis,  82 

in  tubercular  leptomeningitis,  92 
Tachycardia,  139 
Tactile  sense,  50 

testing  of,  50 
Taste,  center  for,  166 


Taste,  electrical  testing  of,  47 

examination  of,  65 

hallucinations  of,  728 

illusions  of,  732 

in  facial  paralysis,  122 

loss  of,  65 

perversions  of,  66 

subjective  sensations  of,  66 
Teeth,  anomalies  of,  704 
Temperature  changes  in  insanity,  753 

examination  of,  24 

in  anterior  poliomyelitis,  377 

in  cerebral  hemorrhage,  205 

in  leptomeningitis,  82 

in  spinal  leptomeningitis,  272 

in  tubercular  leptomeningitis,  91 

localized  elevation  of,  as  a  symptom  in 
brain  disease,  189 
Tender  points  in  sciatic  neuritis,  300 

of  Valleix,  626 
Tenderness  as  a  symptom,  57 

as  a  symptom  of  brain  disease,  189 

in  leptomeningitis,  82 

in  multiple  neuritis,  312 

in  sciatic  neuritis,  299 
Tendon-reflexes  in  leptomeningitis,  83 

in  tubercular  leptomeningitis.  91 
Tendons,  trophic  disorders  of,  38 
Teratoma  of  brain,  254 
Terminal  dementia,  687 
Tetanilla,  526.     See  also  Tetany. 
Tetanus,  521 

antitoxin  in,  523 

cathodal  closing,  44 

cephalic,  522 

diagnosis  of,  522 

etiology  of,  521 

head,  522 

hydrophobicus.  522 

morbid  anatomy  of,  521 

neonatorum,  522 

prognosis  of,  522 

puerperal,  522 

symptoms  of,  521 

treatment  of,  523 

varieties  of,  522 
Tetany,  526 

coui'se  of,  529 

diagnosis  of,  529 

etiology  of,  526 

prognosis  of,  529 

symptoms  of,  527 

treatment  of,  529 
Thermic  sense,  testing  of,  51 
Thermo-analgesia.  51 
Thermo-anesthesia.  51 
Third  nerve,  affection  of,   in  leptomenin- 
gitis, 81 
anatomical  considerations  of,  104 
effect  of  di%nsion  of,  105 
Thomsen's  disease,  552 
diagnosis  of,  554 
etiology  of,  552 
morbid  anatomy  of,  552 
symptoms  of,  553 
treatment  of,  554 
Thoracic  nerve,  posterior,  lesions  of,  287 


INDEX. 


921 


Thought-inhibition,  741 
Thrombosis  a  cause  of  cerfl)ral  soften iug, 
•J1G--J-J4 

of  arteries  of  spinal  cord,  351 

of  sinus,  22tl.     See  also  >siiii(s  throinbDsifi. 
Thronil)otic  softening  of  spinal  cord,  351 
Thyroid  treatment,  496 
Thyroid  in,  497 
Tic,  6-21 

douloureux,  30,  623 

etiology  of.  622 

treatment  of,  (J23 
Tinnitus,  127,  12^! 
Toe-sign  of  Babinski,  36 
Toes,  center  for  moyements  of,  104 
Tongue,  anomalies  of,  704 

motor  center  for,  163 

paralysis  of,  147 
Tonic  conyulsions,  31 

excess  in  cerebellar  disease,  184 

spasm,  30 
Topical  symptoms  in  brain  disease,  189 
Torticollis,  mental,  144,  623 

spasmodic,  143.  623 
Torus  palatinus.  700.  704 
Toxic  influences  in  etiology  of  insanity, 

713 
Trance,  hysterical.  590 
Transitory  mania.  775 
Trausyerse  myelitis.  352 
Traumatic  neuromata,  284 

neuroses,  619 
Tremors,  29 

family,  556 

fibrillary,  29 

hand\yriting  in,  30 

importance  of,  29 

intention,  29 

testing  for,  30 

yolitional,  29 
Trephining  in  cerebral  hemorrhage,  214 

in  leptomeningitis,  87 
Triceps  reflex.  34 

Trifacial  nerye.  anatomical  considerations 
of,  112 
cortical  diseases  of.  113 
disease  of  branches  of.  116 
diseases  of,  112 
nuclear  disease  of,  113 
peripheral   intracranial  affections  of, 
114 

neuralgia,  G28 

neuritis,  116 
Trigeminus.     See  Tr i fa eial  nerve. 
Trigonocephalus.  (i!)5 
Trinitrin  in  angina  pectoris.  142 

in  Raynaud's  disease^  511 
Trional  in  chorea,  541 

in  epilepsy,  614 

in  insanity,  768 

in  mania,  778 

in  neurasthenia.    574 
Trismus.  521 
Trochanteric  point.  300 
Trophic  conditions,  37 

disorders  in  insanity,  751 
Tropho-edema.  chronic  hereditary.  519 


Trophoneuroses,  472 
Trousseau's  sign  of  tetany,  528 
Trunk,  center  for  moyements  of,  164 

neryes  of,  lesions  of,  29() 
Tubercle  of  the  brain,  250 
Tubercular  meningitis,  H9.     See  also  I.ep- 

iomeninc/His,  tidicrcular. 
Tuberculosis  in  etiology  of  insiinity,  717 
Tumors  in   frontal  region,    vertigo  with, 

184 
of  brain.  250 

changes  in  cord  in,  255 

course  of.  258 

diagnosis  of,  259 

etiology  of,  250 

headache  in,  256 

pathological  anatomy  of,  250 

prognosis  of,  261 

symptoms  of,  255 

syphilitic,  253 

treatment  of,  262 

vertigo  in,  257 

vomiting  in,  257 
of  nerves,  283.     See  also  Neurnmata. 
of  spinal  cord,  368 

meninges,  368 
pituitary,  with  acromegaly.  254 
Tuning-fork  in  testing  hearing.  64 
Turkish  baths  in  multiple  neuritis.  323 
Twelfth   cranial    nerve.     See    Hypoglossal 

nerve. 
Typhoid  bacillus  in  leptomeningitis,  78 

Ulxar  nerve,  lesions  of,  291 
Unorientation,  739 
Unsymmetrical  hypertrophies,  517 
Upper  extremity,  center  for  motions  of ,  164 
Urine,  condition  of,  25 

in  insanity,  752 

in  leptomeningitis,  83 

incontinence  of,  23 
Urotropin  in  tabes  dorsalis,  443 
Urticaria,  giant.  513 

in  leptomeningitis,  82 

VAGI'S,  anatomical  considerations  of,  132 

cardiac  branches  of.  139 

diseases  of,  133 
I       gastric  branches  of.  142 

laryngeal  branches  of,  133 

pharyngeal  branches  of,  133 

pulmonary  branches  of,  137 
Valerian  in  myoclonia.  545 
Valleix.  tender  points  of.  626 
Vascular  disorders  in  insanity.  754 
Veins,  cerebral,  anatomy  of.  225 
,    Venereal  history,  importance  of.  in  diag- 
I        nosis  of  nervous  disease,  19 
]   Venesection  in  cerebral  hemorrhage.  214 
Veratrum  in  cerebral  hemorrhage,  214 

^-iride  in  hematomyelia.  351 
Verbigeration.  742.  773 
Verriicktheit.  643 
Vertebral  segments,  relation   of  maximal 

points  of  pain  to.  58 
Vertical  localization  of  a  cord-lesion,  334 

point.  167 


i>22 


INDEX. 


Vertigo  as  symptom,  188 

aural,  1'29.     iSee  also  Aural  vertigo. 

in  brain  lesions,  188 

in  cerebellar  disease,  184 

in  disease  of  labyrinth,  65 

in  epilepsy,  60(i,  608 

in  hysteria,  590 

in  multiple  cerebrospinal  sclerosis,  456 

in  tumors  of  brain,  257 
of  frontal  region,  1^4 
Vestibular  nerve,  irritation  of,  129 
Violence  in  iusane,  management  of,  771 
Virile  reflex,  429 
Visceral  disease,  areas  of  pain  and,  57 

pia,  71 
Vision,  center  for,  105 

electrical  testing  of,  47 

illusions  of,  731 

in  multiple  neuritis,  312 

testing  of.  02 
Visual  aphasia.  174 

field,  02 

in  nervous  diseases,  03 
testing  of,  63 

tract.  96 
Volitional  tremor.  29 
Vomiting  a.s  a  cerebral  symptom,  188 

in  leptomeningitis.  80 

in  lesions  of  spinal  cord,  337 

in  tabes  dorsalis.  427 

in  tubercnlar  meningitis,  100 

in  tumor  of  brain,  257 

projectile,  as  a  symptom,  188 

Wahxsixx.  643.  673,  074 
Wasting  palsy,  389 

Weakness,  muscular,  in   leptomeningitis. 
81 

of  judgment.  740 
Weber,  symptom  group  of,  108 

syndrome,  182 


Weber's  test,  427 

Weichselbaum's  diijlococcus  in  lej^tonur.- 

ingitis,  78 
Wernicke's  classification  of  psychoses,  cr,L 
hemianopic  pupillary  reaction,  99 
sign,  33 
Westplial's  sign,  423 
Whisky  in  angina  pectoris,  142 
White  cerebral  softening,  217 

matter  of  cord,  lesions  of,  410 
Wildermuth's  Aztec  ear,  707 

ear,  707,  709 
Word  memories,  168 

stability  of,  170 

storage  of,  169 
Word-blindness,  explanation  of  producti(.;i 

of,  99 
lesion  causing,  166 
Word-centers,  168 
Word-deafness,  128, 172 

lesion  causing,  166 
Wormian  bones,  significance  of.  097 
Wrist,  center  for  movements  of,  164 
Wrist-clonus,  34 
Writers'  cramp,  57 

course  of.  561 

diagnosis  of,  561 

etiology  of,  557 

motor  disorders  of,  558 

pathology  of,  557 

prognosis  of,  561 

sensory  disorders  in,  501 

symptoms  of,  56S 

treatment  of,  562 
Written  speech,  perception  of,  68 
Wryneck,  spasmodic,  143 

Yellow  cerebral  softening,  217 


ZoxA,  324. 
Zoster,  324. 


See  also  Herpes  zoster. 
See  also  Herpes  zoster. 


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omy and  Operative  Technic  involved  in  the  Operations  of  General 
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si/RGERY  .i.vn  .LYATnAry 


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SURGERY  AND  ANATOMY 


InLterrvation.al 
Text-Book  of  Surgery 

SECOND  EDITION.  THOROVGHLY  REVISED  AND  ENLARGED 

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teen colored  lithographic  plates. 


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Annak-ls  of  Surgery 

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American 
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American  Text=Book  of  Surgery.  Edited  by  William  W.  Keen, 
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Krause's  method  of  skin-grafting,  etc. 


PERSONAL  AND  PRESS  OPINIONS 

Edmund  Owen,  F.R..C.S., 

Member  of  the  Board  of  Examiners  of  the  Royal  College  of  Surgeons,  England. 
"  Personally,  I  should  not  mind  it  being  called  The  Text-Book  (instead  of  A  Text-Book),  for  I 
know  of  no  single  volume  which  contains  so  readable  and  complete  an  account  of  the  science  and  art 
of  surgery  as  this  does." 

The  LaLivcet.  London 

"  If  this  text-book  is  a  fair  reflex  of  the  present  position  of  American  surgery,  we  must  admit  it 
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laurels  if  they  are  to  preserve  a  position  in  the  van  of  surgical  practice." 

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"  This  book  marks  an  epoch  in  American  book-making.  All  in  all,  the  book  is  distinctly  the 
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condensed." 


SURGER  V  AND  A  A' A  TO  MY 


Sc\idder*s 
Treatment  of  Fractures 

The  Treatment  of  Fractures.  By  Charles  L.  Scudder,  M.D., 
Assistant  in  Clinical  and  Operative  Surgery,  Harvard  Medical  School ; 
Surgeon  to  the  Out-Patient  Department  of  the  Massachusetts  General 
Hospital,  Boston.  Handsome  octavo  volume  of  485  pages,  with 
645  original  illustrations. 

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THE  THIRD  LARGE  EDITION  IN  TWO  YEARS 

In  this  edition  several  new  fractures  have  been  described,  and  an  excellent 
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the  important  facts  regarding  fractures  produced  by  the  small  caliber  bullet  have 
been  here  concisely  presented.  In  many  instances  photographs  have  been  substi- 
tuted for  drawings,  and  the  uses  of  plaster-of-Paris  as  a  splint-material  have  been 
more  fully  illustrated.  In  t];ie  treatment  the  reader  is  not  only  told,  but  is  shozu7i, 
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There  are  645  of  them,  all  from  new  and  original  drawings  and  reproduced  in 
the  highest  style  of  art. 


PERSONAL  AND  PRESS  OPINIONS 

William  T.  Bull.  M.D.. 

Professor  of  Surgery,  College  of  Physicians  and  Surgeons,  New  York  City. 
"  The  work  is  a  good  one,  and  I  shall  certainly  recommend  it  to  students."  V 

Joseph  D.  Brya.nt,  M.D.. 

Professor  of  the  Pj-inciples  and  Practice  of  Surgery,  University  and  Bellevue  Hospital 
Medical  College,  New  York  Citv. 
"  As  a  practical  demonstration  of  the  topic  it  is  excellent,  and  as  an  example  of  bookmaking  it 
is  highly  commendable." 

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the  injured  part  is  well  described,  and  .  .  .  the  method  of  making  these  examinations  is  illus- 
trated by  a  liberal  use  of  cuts." 


SAUNDERS'  BOOKS  ON 


Senn's 
Practical  Surgery 

Practical  Surgery.  A  Work  for  the  General  Practitioner.  By 
Nicholas  Senn,  M.D.,  Ph.D.,  LL.D.,  Professor  of  Surgery  in  Rush 
Medical  College,  Chicago  ;  Professor  of  Surgery  in  the  Chicago  Poly- 
clinic ;  Attending  Surgeon  to  the  Presbyterian  Hospital,  etc.  Hand- 
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DR.  SENN'S  GREAT  WORK 
Based  on  His  Operative  Experience  for  25  Years 

This  work  represents  the  practical  operative  experience  of  the  author  for  the 
last  twenty-five  years.  The  book  deals  with  practical  subjects,  and  its  contents 
are  devoted  to  those  sections  of  surgery  that  are  of  special  interest  to  the  general 
practitioner.  Special  attention  is  paid  to  emergency  surgery.  Shock,  hemor- 
rhage, and  wound  treatment  are  fully  considered.  All  emergency  operations 
that  come  under  the  care  of  the  general  practitioner  are  described  in  detail  and 
fully  illustrated. 

The  section  on  Military  Surgery  is  based  on  the  author's  experience  as 
chief  of  the  operating  staff  in  the  field  during  the  Spanish-American  War,  and 
on  his  observations  during  the  Greco-Turkish  War.  Intestinal  Surgery  is  given 
a  prominent  place,  and  the  consideration  of  this  subject  is  the  result  of  the 
clinical  experience  of  the  author  as  surgeon  and  teacher  of  surgery  for  a  quarter 
of  a  century.     The  text  is  profusely  illustrated. 


OPINIONS  OF  THE  MEDICAL  PRESS 

Arsnacls  of  Surgery 

"  It  is  of  value  not  only  as  presenting  comprehensively  the  most  advanced  teachings  of  modern 
surgery  in  the  subjects  which  it  takes  up,  but  also  as  a  record  of  the  matured  opinions  and  practice  of 
an  accomplished  and  experienced  surgeon." 

Qu&rterly  Medical  Journal,  England 

"  We  cannot  speak  too  highly  of  this  valuable  contribution  to  the  literature  of  practical  surgery. 
.   .   .   The  present  work  more  than  sustains  the  high  reputation  of  its  author." 

Buffalo  Medical  Journal 

"As  an  intelligent  exposition  of  the  science  of  surgery  as  practiced  to-day  it  is  deserving  o< 
commendation,  and  it  will  be  particularly  welcomed  by  the  general  practitioner." 


SURGER  Y  AND  ANA  TOMY 


McClellan's 
Art    Anactorrvy 

Anatomy  in  its  Relation  to  Art.  An  exposition  of  the  Bones 
and  Muscles  of  the  Human  Body,  with  Reference  to  their  Influence 
upon  its  Actions  and  external  Form.  By  George  McClellan,  M.D., 
Professor  of  Anatomy,  Pennsylvania  Academy  of  the  Fine  Arts. 
Handsome  quarto  volume,  9  by  ii^  inches.  Illustrated  with  338 
original  drawings  and  photographs,  with  260  pages  of  text. 

Dark  Blue  Vellum,  ^10.00  net;   Half  Russia,  $12.00  net 

Jvist  Iss\ied 

This  is  an  exhaustive  work  on  the  structure  of  the  human  body  as  it  affects 
the  external  form,  and  although  especially  prepared  for  students  and  lovers  of 
art,  it  will  prove  very  valuable  to  all  interested  in  the  subject  of  anatomy.  It 
will  be  of  especial  value  to  the  physician,  because  nowhere  else  can  he  find  so 
complete  a  consideration  of  surface  anatomy.  Those  interested  in  athletics  and 
physical  training  will  find  reliable  information  in  this  book. 

Howard  Pyle, 

In  the  Philadelphia  Medical  Journal. 
"  The  book  is  one  of  the  best  and  the  most  thorough  Text-books  of  artistic  anatomy  which  it  has 
been  the  writer's  fortune  to  fall  upon  and,  as  a  text-book,  it  ought  to  make  its  way  into  the  field  for 
which  it  is  intended." 

McClellan's 
R.egior^aJ  Ar\©cton\y 

Regional  Anatomy  in  its  Relations  to  Medicine    and   Surgery. 

By  George  McClellan,  M.D.,  Professor  of  Anatomy,  Pennsylvania 
Academy  of  the  Fine  Arts.  Two  handsome  quartos,  884  pages  of  text ; 
97  full-page  chromolithographic  plates,  reproducing  the  author'  s  orig- 
inal dissections.  Cloth,  ;^  12.00  net;    Half  Russia,  ;^  15.00  net. 

Fourth  ILevised  Edition 

This  well-known  work  stands  without  a  parallel  in  anatomic  literature,  and  its 
remarkably  large  sale  attests  its  value  to  the  practitioner.  By  a  marvelous  series 
of  colored  lithographs  the  exact  appearances  of  the  dissected  parts  of  the  body 
are  reproduced,  enabling  the  reader  to  examine  the  anatomic  relations  with  as 
much  accuracy  and  satisfaction  as  if  he  had  the  actual  subject  before  him. 

British  Medical  Journal 

"The  illustrations  are  perfectly  correct  anatomical  studies,  and  do  not  reproduce  the  inaccura- 
cies which  experience  has  taught  us  to  look  for  in  works  of  a  similar  kind.  Some  of  the  plates 
especially  those  of  the  anatomy  of  the  chest,  are  of  great  excellence." 


SAUNDERS'  BOOKS  ON 


D©cCosta».'s 

Moderrv    S\irgery 

Modern  Surgery — General  and  Operative.  By  John  Chalmers 
DaCosta,  M.D.,  Professor  of  the  Principles  of  Surgery  and  of  Clini- 
cal Surgery  in  the  Jefferson  Medical  College,  Philadelphia  ;  Surgeon 
to  Philadelphia  Hospital  and  to  St.  Joseph's  Hospital,  Philadelphia. 
Handsome  octavo  volume  of  1117  pages,  copiously  illustrated. 

Cloth,  ^5.00  net ;  Sheep  or  Half  Morocco,  ^6.00  net. 

FOURTH  REVISED  EDITION  — JUST  ISSUED 

Thoroughly  Revised,  Entirely  Reset,  and  Greatly  Enlarged 


The  remarkable  success  attending  DaCosta's  Manual  of  Surgery,  and  the 
general  favor  with  which  it  has  been  received,  have  led  the  author  in  this  revi- 
sion to  produce  a  complete  treatise  on  modern  surgery  along  the  same  lines  that 
made  the  former  editions  so  successful.  The  book  has  been  entirely  rewritten 
and  very  much  enlarged  in  this  edition.  It  has  been  greatly  increased  in  size 
by  the  addition  of  new  matter,  and  contains  more  than  100  handsome  new  illus- 
trations, making  a  total  of  439  beautiful  cuts  in  the  text.  The  old  editions  of 
this  excellent  work  have  long  been  favorites,  not  only  with  students  and  teachers 
but  also  with  practising  physicians  and  surgeons,  and  it  is  believed  that  the 
present  work,  presenting,  as  it  does,  the  latest  advances  in  the  science  and  art 
of  surgery,  will  find  an  even  wider  field  of  usefulness. 


OPINIONS  OF  THE  MEDICAL  PRESS 

The  Lancet,  London 

"  We  may  congratulate  Dr.  DaCosta  in  the  success  of  his  attempt.  .  .  .  We  can  recommend 
the  work  as  a  text-book  well  suited  to  students." 

The  Medical  R.ecord,  New  York 

"  The  work  throughout  is  notable  for  its  conciseness.  Redundance  of  language  and  padding 
have  been  scrupulously  avoided,  while  at  the  same  time  it  contains  a  sufficient  amount  of  information 
to  fulfil  the  object  aimed  at  by  its  author — namely,  a  text-book  for  the  use  of  the  student  and  the 
busy  practitioner." 

American  Journal  of  the  Medical  Sciences 

"  The  author  has  presented  concisely  and  accurately  the  principles  of  modern  surgery.  The 
book  is  a  valuable  one,  which  can  be  recommended  to  students,  and  is  of  great  value  to  the  general 
practitioner." 


SURGER  V  AND  ANA  TOMY 


GET  A        ^^  •  THE  NEW 

THE  BEST         XTL  nrV  C  n  C  Qk- rV       standard 

Ill\istra^ted  Dictiorva^ry 

THIRD  REVISED  EDITION  — JUST  ISSUED 

The  American    Illustrated    Medical    Dictionary.      A    New    and 

Complete  Dictionary  of  the  terms  used  in  Medicine,  Surgery,  Den- 
tistr\-,  Pharmacy,  Chemistry,  and  kindred  branches.  With  tables  of 
Arteries,  Muscles,  Nerves,  Veins,  etc.;  of  Bacilli,  Bacteria,  etc.; 
Epon}-mic  Tables  of  Diseases,  Operations,  Stains,  Tests,  etc.  By 
W.  A.  Newman  Dorland,  M.D.      Large  octavo,  798  pages. 

Flexible  leather,  :^4. 50  net;  with  thumb  index,  $5.00  net. 

Howard  A.  Kelly,  M.D., 

Professor  of  Gynecology,  Johns  Hopkins  University,  Baltirnore. 

"  Dr.  Dorlaiid's  Dictionary  is  admirable.  It  is  so  well  gotten  up  and  of  such  convenient  size. 
No  errors  have  been  found  in  my  use  of  it." 

American  Year-Book 

Saunders'    American    Year  =  Book    of     Medicine    and    Surgery. 

A  yearl}^  Digest  of  Scientific  Progress  and  x'\uthoritative  Opinion  in  all 
branches  of  Medicine  and  Surgery.  Arranged,  with  critical  editorial 
comments,  by  eminent  American  specialists,  under  the  editorial  charge 
of  George  M.  Gould,  A.M.,  M.D.  In  two  volumes  :  Vol.  I — 
General  Medicine,  octavo,  715  pages,  illustrated;  Vol.  II — General 
Surgery,  octavo,  684  pages,  illustrated.  Per  vol. :  Cloth,  ^3.00  net; 
Half  Morocco,  $3.75  net.      Sold  by  Subscription. 

The  Lancet,  London 

"  It  is  much  more  than  a  mere  compilation  of  abstracts,  for,  as  each  section  is  entrusted  to 
experienced  and  able  contributors,  the  reader  has  the  advantage  of  certain  critical  commentaries  and 
expositions     .     .     .     proceeding  from  writers  fully  qualified  to  perform  these  tasks." 

HelfericK  ai\d  Bloodgood's 
Fract\ires  and  Dislocations 

Atlas  and   Epitome  of  Traumatic  Fractures  and   Dislocations. 

By  Prof.  Dr.  H.  Helferich,  of  Greifswald,  Prussia.  Edited,  with 
additions,  by  Joseph  C.  Bloodgood,  M.D.,  Associate  in  Surgery, 
Johns  Hopkins  University,  Baltimore.  From  the  Fifth  Revised  and 
Erdarged  German  Edition.  216  colored  figures  on  64  lithographic 
plates,  190  text-cuts,  and  353  pages  of  text. 

Cloth,  ^3.00  net.      In  Saunders'' Atlas  Series. 

Medical  News,  New  York 

"  The  author  and  editor  have  made  a  most  successful  effort  to  arrange  the  illustrations  that  the 
interpretation  of  what  they  are  intended  to  present  is  exceedingly  easy." 


SAUNDERS'   BOOKS  ON 


Sviltecrv  ©crvd  Coley's 
Abdonrvirval  Herrvia^s 

Atlas  and  Epitome  of  Abdominal  Hernias.  By  Pr.  Dr.  G.  Sul- 
tan, of  Gottingen.  Edited,  with  additions,  by  Wm.  B.  Coley,  M.D., 
Clinical  Lecturer  on  Surgen,^,  Columbia  University,  New  York.  119 
illustrations,  36  in  colors,  and  277  pages  of  text. 

Cloth,  $3.00  net.      In  Saunders'  Hand-Atlas  Series. 

Robert  H,  M.  Dawbarn.  M.D., 

P7'ofessor  of  Sui'gery  and  of  Surgical  Anatoniy,  Nezu  York  Polvclinic. 

"  I  have  spent  several  interesting-  hours  over  it  to-day,  and  shall  willingly  recommend  it  to  vay 
classes  at  the  Polyclinic  College  and  elsewhere." 

Warren's  Pathology  and  Therapeutics 

Surgical  Pathology  and  Therapeutics.     By  J.  Collins  Warren, 
M.D.,  LL.D.,  F.R.C.S.  (Hon.),  Professor  of  Surgery,  Harvard  Medi- 
cal   School.      Octavo,    873    pages;     136   illustrations,    33    in    colors. 
With  an  Appendix  on  Surgical  Diagnosis  and  Regional  Bacteriology. 
Cloth,  $5.00  net ;   Sheep  or  Half  Morocco,  ^6.00  net. 
SECOND   EDITION,  WITH   AN  APPENDIX 

Roswell  Park,  M.D., 

In  the  Hari'ard  Graduate  Magazine. 

■'  Ithink  it  is  the  most  creditable  book  on  surgical  pathology,  and  the  most  beautiful  medical 
illustration  of  the  bookmakers"  art  that  has  ever  been  issued  from  the  American  press." 

ZuckerkaLndl  and  DaLCostdL's 
Opera..tive   Svirgery 

ADOPTED   BY   THE   U.   S.   AR.MY 

Atlas  and  Epitome  of  Operative  Surgery.  By  Dr.  O.  Zucker- 
KANDL,  of  Vienna.  Edited,  Avith  additions,  by  J.  Chalmers  DaCosta, 
M.D.,  Professor  of  the  Principles  of  Surgery  and  Clinical  Surgery, 
Jefferson  Medical  College,  Phila.  40  colored  plates,  278  text-cuts, 
and  410  pages  of  text.      Cloth,  $3.50  net.     In  Sannders'  Atlas  Series. 

SECOND  EDITION,  THOR.OVGHLY  REVISED  AND  GREATLY  ENLARGED 

New  York  Medical  Journal. 

"  We  know  of  no  other  work  upon  the  subject  in  which  the  illustrations  are  as  numerous  or  as 
generally  satisfactory," 


SURGERY  AND   ANATOMY  13 

Robson  and  Moynihan  on  the  Pancreas 

Diseases  of  the  Pancreas  and  Their  Surgical  Treatment.  By  A.  W.  Mayo 
Robson,  F.R.C.S.,  Senior  Surgeon,  Leeds  General  Infirmary  ;  Emeritus  Pro- 
fessor of  Surgery,  Yorkshire  College,  Victoria  University,  England  ;  and  B. 
G.  A.  Moynihan,  M.S.  (Lond.),  F.R.C.S.,  Assistant  Surgeon,  Leeds  General 
Infirmary ;  Consulting  Surgeon  to  the  Skipton  and  to  the  Mirfield  Memorial 
Hospitals,  England.     Octavo  of  293  pages,  illustrated.  Cloth,  I3.00  net. 

Quarterly  Medical  Journal,  Sheffield,  England 

"  The  entire  work  bears  the  stamp  of  thoroug-hness,  and  it  will,  we  feel  sure,  receive  the  recog- 
nition to  which  its  extensive  merits  entitle  it." 


SerVrV.    OrV.    XvimOrS  second  R^evised  Edition 

Pathology  and  Surgical  Treatment  of  Tumors.  By  Nicholas  Senn, 
M.D.,  Ph.D.,  LL.D.,  Professor  of  Surgery,  Rush  Medical  College,  Chicago. 
Handsome  octavo,  718  pages,  with  478  engravings,  including  12  full-page 
colored  plates.  Cloth,  $5.00  net;  Sheep  or  Half  Morocco,  |6.oo  net. 

Journal  of  the  American  Medical  Association 

"  The  most  exhaustive  of  any  recent  book  in  Eng-lish  on  this  subject.  It  is  well  illustrated,  and 
will  doubtless  remain  as  the  principal  monograph  on  the  subject  in  our  language  for  some 
years.     The  author  has  given  a  notable  and  lasting  contribution  to  surgery." 


Macdonald's  Diagnosis  and  Treatment 

A  Clinical  Text=Book  of  Surgical  Diagnosis  and  Treatment.     By  J.  W. 

Macdonald,  M.D.  Edin.,  F.R.C.S.  Edin.,  Professor  Emeritus  of  the  Prac- 
tice of  Surgery  and  of  Clinical  Surgery  in  Hamline  University,  Minneapolis, 
Minn.     Octavo,  798  pages,  handsomely  illustrated. 

Cloth,  I5.00  net ;  Sheep  or  Half  Morocco,  |6.oo  net. 

British  Medical  Journa-I 

"  Care  has  been  taken  to  lay  down  rules  for  a  systematic  and  comprehensive  examination  of 
each  case  as  it  presents  itself,  and  the  most  advanced  and  approved  methods  of  clinical  investi- 
gation in  surgical  practice  are  fully  described." 


Golebiewski  a^^nd  Ba.iley's  Accident 
Dise^cses 

Atlas  and   Epitome  of   Diseases    Caused   by  Accidents.      By  Dr.    Ed. 

Golebiewski,  of  Berlin.  Edited,  with  additions,  by  Pearce  Bailey, M.D. , 
Attending  Physician  to  the  Almshouse  and  Incurable  Hospitals,  New  York. 
With  71  colored  figures  on  40  plates,  143  text-cuts,  and  549  pages  of  text. 

Cloth,  I4.00  net.     Iji  Saunders'  Hand- Atlas  Series. 

The  Medical  Record,  New  York 

"  This  volume  is  upon  an  important  and  only  recently  systematized  subject,  which  is  growing 
in  extent  all  the  time.     The  pictorial  part  of  the  book  is  very  satisfactory." 


14  SAUNDERS'    BOOKS   ON 

Haynes*  Anatomy 

A  Manual  of  Anatomy.  By  Irving  S.  Haynes,  ]\I.D.,  Professor  of  Prac- 
tical Anatomj',  Cornell  University  Medical  College.  Octavo,  680  pages, 
with  42  diagrams  and  134  full-page  half-tones.  Cloth,  $2.50  net. 

"  This  book  is  the  work  of  a  practical  instructor — one  who  knows  by  experience  the  require- 
ments of  the  average  student,  and  is  able  to  meet  these  requirements  in  a  very  satisfactory- 
way."' —  The  Medical  Record,  New  York. 

American  Pocket  Dictionary    r„„„h^^;VilJd  Edition 

The  American  Pocket  Medical  Dictionary.  Edited  by  W.  A.  Newman 
Borland,  A.M.,  M.D.,  Assistant  Obstetrician,  Hospital  of  the  University  of 
Pennsylvania,  etc.  566  pages.  Full  leather,  limp,  with  gold  edges,  fi-oo 
net;  with  patent  thumb  index,  I1.25  net. 

"  I  am  struck  at  once  with  admiration  at  the  compact  size  and  attractive  exterior.  I  can  recom- 
mend it  to  our  students  without  reserve." — James  W.  Holland,  M.D.,  Professor  of  Medical 
Chemistry  and  Toxicology,  and  Dean,  feffer son  Medical  College,  Philadelphia. 

Beck's  Fractures 

Fractures.  By  Carl  Beck,  M.D.,  Professor  of  Surgery,  New  York  Post- 
graduate Medical  School  and  Hospital.  With  an  Appendix  on  the  Practical 
Use  of  the  Rontgen  Rays.     335  pages,  170  illustrations.         Cloth,  I3.50  net. 

"  The  use  of  the  rays  with  its  technic  is  fully  explained,  and  the  practical  points  are  brought  out 
with  a  thoroughness  that  merits  high  praise." — The  Medical  Record,  New  York. 

Moynihan's  Gastric  and  Duodenal  Ulcers  ^^^l^ 

The  Surgical  Treatment  of  Gastric  and  Duodenal  Ulcers.     By  B.  G.  A. 

jNIoynihan,  M.S.  (Lond.),  F.R.C.S.  Eng.,  Senior  Assistant  Surgeon,  Leeds 
General  Infirmary,  etc.     Octavo,  illustrated. 

Beautifully  bound  in  cloth,  $2.50  net. 

This  work,  by  a  distinguished  surgeon,  is  a  concise  and  accurate  treatise  on  an  important  sub- 
ject.    The  cases  detailed  will  be  found  of  unusual  interest. 

Stoney's  Surgical  Technic  for  Nurses 

Bacteriology  and  Surgical  Technic  for  Nurses.  By  Emily  A.  M.Stonev, 
Superintendent  of  the  Training  School  for  Nurses  at  the  Carney  Hospital, 
South  Boston,  Mass.     lamo,  200  pages,  illustrated.  Cloth,  $1.25  net. 

"  These  subjects  are  treated  most  accurately  arid  up  to  date,  without  the  superfluous  reading 
which  is  so  often  employed.  .  .  .  Nurses  will  find  this  book  of  the  greatest  value."— 
Trained  Nurse  and  Hospital  Review. 

Grant  on  Face.  Mouth,  and  Jaws 

A  Text=Book  of  the  Surgical  Principles  and  Surgical  Diseases  of  the 
Face,  Mouth,  and  Jaws.  For  Dental  Students,  By  H.  Horace  Grant, 
A.M.,  M.D.,  Professor  of  Surgery  and  of  Clinical  Surgery,  Hospital  College 
of  Medicine.     Octavo  of  231  pages,  with  68  illustrations.       Cloth,  $2.50  net. 

"  The  language  of  the  book  is  simple  and  clear.  .  .  .  We  recommend  the  work  to  those  for 
whom  it  is  intended." — Philadelphia  Medical  fournal. 


SURGER  V  AND  ANA  TOMY 


15 


Warwick  and  Tunstall's  First  Aid 

First  Aid  to  the  Injured  and  Sick.  By  F.  J.  Warwick,  B.A.,  M.B. 
Cantab.,  Associate  of  King's  College,  London  ;  and  A.  C.  Tunstall,  M.D,, 
F.R.C.S.  Edin.,  Surgeon-Captain  Commanding  the  East  London  Volunteer 
Brigade  Bearer  Company.      i6mo  of  232  pages  and  nearly  200  illustrations. 

Cloth,  $1.00  net. 

"  Contains  a  great  deal  of  valuable  information  well  and  tersely  expressed.  It  will  prove 
especially  useful  to  the  volunteer  first  aid  and  hospital  corps  men  of  the  National  Guard." — 
Journal  American  JSIedical  Association. 

Beck's  S\irgical  Asepsis 

A  Manual  of  Surgical  Asepsis.  By  Carl  Beck,  M.D.,  Professor  of  Sur- 
gery, New  York  Post-graduate  Medical  School  and  Hospital.  306  pages  ;  65 
text-illustrations  and  12  full-page  plates.  Cloth,  ^1.25  net. 

"  The  book  is  well  written.  The  data  are  clearly  and  concisely  given.  The  facts  are  well 
arranged.  It  is  well  worth  reading  to  the  student,  the  physician  in  general  practice,  and  the 
surgeon." — Boston  Medical  and  Surgical  Journal. 

Pye's  Bandaging 

Elementary  Bandaging  and  Surgical  Dressing.  With  Directions  con- 
cerning the  immediate  Treatment  of  Cases  of  Emergency.  By  Walter 
Pye,  F.R.C.S.,  late  Surgeon  to  St.  Mary's  Hospital,  London.  Small  i2mo, 
over  80  illustrations.  Cloth,  flexible  covers,  75  cts.  net. 

"  The  author  writes  well,  the  diagrams  are  clear,  and  the  book  itself  is  small  and  portable, 
although  the  paper  and  type  are  good." — British  Medical  Journal, 

Senn's  Syllabus  of  Surgery 

A  Syllabus  of  Lectures  on  the  Practice  of  Surgery.  Arranged  in  con- 
formity with  "American  Text-Book  of  Surgery."  By  Nicholas  Senn, 
M.D.,  Ph.D.,  LL.D.,  Professor  of  Surgery,  Rush  Medical  College,  Chicago. 

Cloth,  $1.50  net. 

"  The  author  has  evidently  spared  no  pains  in  making  his  Syllabus  thoroughly  comprehensive, 
and  has  added  new  matter  and  alluded  to  the  most  recent  authors  and  operations.  Full  refer- 
ences are  also  given  to  all  requisite  details  of  surgical  anatomy  and  pathology."— j5>'zVz>A  Medi- 
cal Journal. 

Keen's  Operation  Blank,  Second  Edition,  R^evlsed  Form 

An  Operation  Blank,  with  Lists  of  Instruments,  etc.,  Required  in  Various 
Operations.  Preparedby  Wm.  W.  Keen,  M.D.,LL.D.,  F.R.C.S.  (Hon.),  Pro- 
fessor of  the  Principles  of  Surgery  and  of  Clinical  Surgery,  Jefferson  Medical 
College,  Philadelphia.      Price  per  pad,  blanks  for  fifty  operations,  50  cts.  net. 

"  Will  serve  a  useful  purpose  for  the  surgeon  in  reminding  him  of  the  details  of  preparation  for 
the  patient  and  the  room  as  well  as  for  the  instruments,  dressings,  and  antiseptics  needed." 
— ISeiu  York  Medical  Record. 

Keen  on  tKe  Surgery  of  Typhoid 

The  Surgical  Complications  and  Sequels  of  Typhoid  Fever.     By  Wm.  W. 

Keen,  M.D.,  LL.D.,  F.R.C.S.  (Hon.),  Professor  of  the  Principles  of  Surgery 
and  of  Clinical  Surgery,  Jefferson  Medical  College,  Philadelphia,  etc. 
Octavo  volume  of  386  pages,  illustrated.  Cloth,  $3.00  net. 

"  Every  surgical  incident  which  can  occur  during  or  after  typhoid  fever  is  amply  discussed  and 
fully  illustrated  by  cases.  .  .  .  The  book  will  be  useful  both  to  the  surgeon  and  physician." — 
The  Practitioner,  London. 


1 6  SUR  GER  V  AND  ANA  TO  MY 

Moore's  Orthopedic  Surgery 

A  Manual  of  Orthopedic  Surgery.  By  James  E.  Moore,  M.D.,  Professor 
of  Clinical  Surgery,  University  of  Minnesota,  College  of  Medicine  and  Surgery. 
Octavo  of  356  pages,  handsomely  illustrated.  Cloth,  $2.50  net. 

"  The  book  is  eminently  practical.  It  is  a  safe  guide  in  the  understanding  and  treatment  of 
orthopedic  cases.     Should  be  owned  by  every  surgec  a  and  practitioner." — Annals  of  Surgery. 

Nancrede's   Anatomy  and   Dissection.     Ediiron 

Essentials    of    Anatomy   and    Manual    of    Practical    Dissection.      By 

Charles  B.  Nancrede,  M.D.,  Professor  of  Surgery  and  of  Clinical  Surgery, 
University  of  Michigan,  Ann  Arbor.  Post-octavo  ;  500  pages,  with  full-page 
lithographic  plates  in  colors,  and  nearly  200  illustrations. 

Extra  Cloth  (or  Oilcloth  for  the  dissecting-room),  $2.00  net. 

"  The  plates  are  of  more  than  ordinary  excellence,  and  are  of  especial  value  to  students  in  their 
work  in  the  dissecting-room."— yo?(?K'a/  of  the  American  Medical  Associatiott. 

Nancrede's  Principles  of  Surgery 

Lectures  on  the  Principles  of  Surgery.  By  Chas.  B.  Nancrede,  M.D., 
LL.D.,  Professor  of  Surgerj'  and  of  Clinical  Surgery,  University  of  Michigan, 
Ann  Arbor.     Octavo,  398  pages,  illustrated.  Cloth,  $2.50  net. 

"  We  can  strongly  recommend  this  book  to  all  students  and  those  who  would  see  something 
of  the  scientific  foundation  upon  which  the  art  of  surgerv  is  built." — Quarterly  Medical  Journal, 
Sheffield,  England. 

Nancrede's  Essentials  of  Anatomy.   ^^'^Edmon^^'* 

Essentials  of  Anatomy,  including  the  Anatomy  of  the  Viscera.     By  Chas. 

B.  Nancrede,  M.D.,  Professor  of  Surgery  and  of  Clinical  Surgery,  University 

of  Michigan,  Ann  Arbor.     Crown  octavo,  388  pages  ;   180  cuts.     With  an 

Appendix  containing  over  60  illustrations  of  the  osteology  of  the  body.     Based 

on  Gray  s  Anatomy .  Cloth,  $1.00  net.     In  Saunders    Qiiestio7i  Compends. 

"  The  questions  have  been  wisely  selected,  and  the  answers  accurately  and  concisel}-  given." — 
University  Medical  Magazine. 

Martin's   Essentials  of   Surgery.     ^^'^XviEd*'*''" 

Essentials  of  Surgery.  Containing  also  Venereal  Diseases,  Surgical  Land- 
marks, Minor  and  Operative  Surgery,  and  a  complete  description,  with  illus- 
trations, of  the  Handkerchief  and  Roller  Bandages.  By  Edward  Martin, 
A.M.,  M.D.,  Professor  of  Clinical  Surgery,  Lfniversity  of  Pennsylvania,  etc. 
Crown  octavo,  338  pages,  illustrated.  With  an  Appendix  on  Antiseptic  Sur- 
gery, etc.  Cloth,  $1.00  net.      /;/  Saunders   Question  Co7npends. 

"  Written  to  assist  the  student,  it  will  be  of  undoubted  value  to  the  practitioner,  containing  as  it 
does  the  essence  of  surgical  work." — Boston  Medical  and  Surgical  Journal. 

Martin's   Essentials  of  Minor  Surgery,  Band- 
aging,   and   Venereal    Diseases.       ^^*'*'£dit^on^*^^'* 

Essentials  of  Minor  Surgery,  Bandaging,  and  Venereal  Diseases.    By 

Ed\vard  Martin,  A.M.,  M.D.,  Professor  of  Clinical  Surgery,  University  of 
Pennsylvania,  etc.   Crown  octavo,  166  pages,  with  78  illustrations. 

Cloth,  $1.00  net.     In  Saunders'  Question  Co7npe7ids. 

"The  best  condensation  of  the  subjects  of  which  it  treats  yet  placed  before  the  profession." — 

The  Medical  News,  Philadelphia. 


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